HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 186 INGALLS STREET 11/12/2019 : Commonwealth of Massachusetts RECEIVED
City/Town of NOV 12 2019
System Pumping Record TOWN 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 hou ft i r f ho , Left/right side of house, Left
Right side of building, Left/Right front of b ' g, Le g _ rear of building, Under deck
Address
cityRown Smote Zip Code
2. System Owner.
Name"
Address(if different from location)
CityfTown
Telephone Number
B. Pumping record
1. Date of Pumping oat 2. Quantity Pumped: Gallons
3. Type-of system: ❑ Cesspool(s) ptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? es ❑ No If yes, was it cleaned? es ❑ No
5. Condition of System:���`���
6. System Pumped By:
Neil.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Lo ' n re content were disposed:
GLLSQ Lowell Waste Water r,�
C2
Sign a Haul Date
t5fomn4.doc-06/03 System Pumping Record•Page 1 of 1