HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 123 MARIAN DRIVE 9/20/2019 Commonwealth of Massachusetts RECEIVE®
City/Town of
System Pumping Record SEF 2 0 2o1a
Form 4 TOWN OF NORTH ANDOVER
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 house, Left kf YSPg7iir_o_f-_h_o_u_s-eLeft/right side of house, Left
Right side of building, Left/Right front of building, Left TRRJhT rear of building, Under deck
Address ! � o`C' cc,V1 ��� v.Q,_ �j .�
City/Town b State Zip Code
2. System Owner.
Name
Address(if different from location)
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? U-Ye 0 No If yes, was it cleaned? [-Yes No
5. Condition of System:
6. System Pumped By:
Neil.Batesbri F5821
Name Vehicle License Number
Bateson Enterprises Ina
Company
7. Locatio contents-were disposed:
.L S: Lowell Waste Water
ClWa&A. q - L
signAie CfHaulmu Date
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