HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 33 CRICKET LANE 11/19/2019 Commonwealth of Massachusetts RECEIVED
City/Town of NOV 19 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 Right ear of house Deft/right side of house, Left
Right side of building, Left/Right front of bdiffidiffig, Left/Righ rear of building, Under deck
Address
Lj JV A tCt ty�
City/Town State Zip Code
2. System Owner.
Name'
Address(f different from location)
CivTown State Zip Code
fed - S
Telephone Number
B. Pumping Record q
1. Date of Pumping Date+ ' ! _ ( / Quantity Pumped: Gallons
3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
Oi co,-, I W (,e
6. System Pumped By.
Neil.Bateson F5821
Name Vehicle Ltoense Number
Bateson Enterprises Inc
Company
7. Loca'o re contents,were disposed:
G L S Lowell Waste Water
signk4e cf Haul Date
tmom-A.docr 06/03
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