HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 53 BROOKVIEW DRIVE 10/30/2019 Commonwealth of Massachusetts RECEIVED
_ City/Town of OCT 3 0 2019
System Pumping Record TOWN OF NORTH ANDUVER
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 Ahis 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/Right rear of house, Left/ ' I e of house Left
Right side of building, Left/Right front of building, Left/Right rear of building, Under deck
Address
CWTown State Zip Code
2. System Owner.
Name
Address(f different from location)
City/Town $fate Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping Da e( F �� Quantity Pumped:
Gallons
3. Type of system: ❑ Cesspool(s) ptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes Ld'No - 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. Loca' e contents were disposed:
'US'USJP Lowell Waste Water
4Signa Haul Date
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