HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 623 OSGOOD STREET 9/9/2019 Commonwealth of Massachusetts RECEIVED
City/Town of
System Pumping Record
Form 4 TOWN OF NORTH ANDOVER
HEALTH DEPARTMENT
DEP has provided this form for use=by local Boards of Health. Other forms may be*used,but the
information must be substantially the same as that provided here. Before using.this form,check with your
local Board of Health to determine the form they use.The System Pumping Record must be submitted to
the local Board of Health or other approving authority.
A. Facility Information
1. System Location: Lefight fr'o-nf of house t.eft/Right rear of house, Left/right side of house, Left
Right side of building, g ron o uiidirig, Left/Right rear of building, Under deck
Address ;�- L �
cfwrown State Zip Code
2. System Owner.
C.� r
Name
Address(if different from location)
CityfTown State
/// Zip Code
SI
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Type of system: ❑ Cesspool(s) ptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes jA If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System r
4-2-
6. System Pumped By:
Neil.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc-
Company
7. Lopation3uliere content were disposed:
G L Lowell Waste Water
Signitule Haut Date
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