HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 133 COLONIAL AVENUE 11/19/2019 : Commonwealth of Massachusetts RECEIVED
City/Town of NOV 19 2019
System Pumping Record
Form 4 TOWN OF NORTH ANDOVER
HMTH DEPARTMENT
DEP has provided this form for use by local Boards of Health. Other forms may be'used,but the
information-must be substantiaffy 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 I hf rear of hous�a Left/right side of house, Left/
Right side of building, Left/Right front of building, Left/Right rear of building, Under deck
Address
(City/Town �c��r►�2 I'� �_�G�a vim'
state Zip Code
2. System Owner.
Coo S b=_,"LA
Name
Address(if different from location)
CitylTovun State Zip Code
-72g --
Telephone Number
B. Pumping Record q
1. Date of Pumping oat a r 1 t Quantity Pumped: / �0
Gallons
3. Type of system: ❑ Cesspool( Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes No If yes,was it cleaned? ❑ Yes ❑ No
5. Condition of System:
r
6. System Pumped By:
Neil.Batesbn F5821
Name Vehicle License Number
_Bateson Enterprises Inc
Company
7. Location where contents were disposed:
/-_G�,L. P Lowell Waste Water
Signitufe 9t HauWU Date t
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