HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 63 BRADFORD STREET 9/20/2019 : Commonwealth of Massachusetts
City/Town of SEP 20 2019
System Pumping Record TOVM OF NORTH ANDOVER
Form 4 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: Left/Right front of house, Left , Left/right side of house, Left
Right side of building, Left/Right front of building, Left/Right rear of building, Under deck
Address ft G 3— �v q
Myrrown State Zip Code
2. System Owner.
Name'
Address(if different from location)
CityfTownAD Code
Telephone Number
6. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Type-of system: ❑ Cesspool(s) eptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes LSO If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System: rvC�c-✓�f� �V/,�� � ����_
6. System Pumped By:
Neil.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Ina
Company
7. Locatiopne
contents-were disposed:
G.L.&P Lowell Waste Water
Sign We cf Haul Date
t5form4.doa 08/03 System Pumping Record•Page 1 of 1