HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 146 DEER MEADOW ROAD 11/19/2019 Commonwealth of Massachusetts RECEIVE®
_ City/Town of NOV 19 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 i ht front of hour.Left/Right rear of house, Left/right side of house, Left
Right side of building, Left/Right fron of building, Left/Right rear of building, Under deck
Address
�V1>vez I�j . do
City/Town State Zip Code
2. System Owner.
Name
Address(if different from locafion)
City/Town State Zip Code
� TO
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2. antity Pumped: Gallons
3. Type of system: ElCesspool(s) Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? [I/'Yes ❑ 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. Location where contents were disposed:
rGLL S Lowell Waste Water
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Sign a Haul Date l
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