HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 185 MILL ROAD 11/19/2019 Commonwealth of Massachusetts RECEIVED
City/Town of
System Pumping Record Nov 19 2019
Form 4 TOWN OF NORTH ANDOVER
IjEALTH 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/%' t;7��f house,�Left/Right rear of house, Left/right side of house, Left 1
Right side of bul�ding, Ln of building, Left/Right rear of building, Under deck
Address
City/rown State Zip Code
2. System Owner. f ,
Name' v
Address(if different from location)
CWTawn State_
Telephone Number
B. 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 o If yes,was it cleaned? ❑ Yes ❑ No
5. Condition of System:
6. System Pumped By:
Neil.Meson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Location ere contents were disposed:
_L S Lowell Waste Water
Sign We 9t Hhul Date
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