HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 19 CANDLESTICK ROAD 9/20/2019 : Commonwealth of Massachusetts RF �3` ®
City/Town of
System Pumping Record SEP 2 0 2019
Form 4 TOWN OF NORTH ANDOVER
HEALTH DER';
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: Left/Right front of hou R)g �o�ho , Left/right side of house, Left/
Right side of building, Left/Right front of b trig, Left building, Under deck
Address t q
Citylrown State Zip Code
2. System Owner.
Name'
Address(if different from location)
Telephone Number
.B. Pumping Record
1. Date of Pumping �
p g Date 2. Quantity Pumped:
Gallons
3. Type-of system: ❑ Cesspool(s) ptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes o If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
6. System Pumped By:
Neil.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Locafibn where content&were disposed:
G.t_S Lowell Waste Water
Signitufe qt Haut Date
t5fbrm4.doa 06/03
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