HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 60 LONG PASTURE ROAD 11/19/2019 RECI*I,v-j)
Commonwealth of Massachusetts NOV 19 ZUly
City/Town of TOWN OF NORTH ANDOVER
System Pumping Record HEALTH DEPARTMENT
Form 4
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 foram,check with your
local Board of Health to determine the forrh 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, / - e of hou kLeft 1
Right side of building, Left/Right front of building, Left/Right rear of building, Uh er
Address C SC S(2-
CityRo" State Zip Code
2. System Owner:
Name'
Address(if different from location)
City/Town
Telephone Number
B. Pumping Record
1. Date of Pumping Date �� �Quantjiped: Gallons
3. Type of system: ❑ Cesspool(s) ptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
1
6. System Pumped By:
Neil.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Lo9eqt1HftauW1'eWrU
contents were disposed:
7 Lowell Waste Water ( �(
aA
SigDate
t5fomu4.doc•06/03
System Pumping Record•Page 1 of 1