HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 336 CANDLESTICK ROAD 9/9/2019 SrN Commonwealth of Massachusetts R E C 1V9ZD
City/Town of r,
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 beused, 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 a ig �rontof house, ibft/Right rear of house, Left/right side of house, Left
Right side of bui�ft/ uilding, Left/Right rear of building, Under deck
Address
City/Town State Zip Code
2. System Owner.
Name
Address(if different from location)
City/Town State _
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes LSO If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of Syitem,
6. System Pumped By:
Neil.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc-
Company
7. Locatio ere contents were disposed:
G L S Lowell Waste Water
Sign a Haul Date
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