HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 154 REA STREET 11/19/2019 Commonwealth of Massachusetts RECEIVED
City/Town of
System Pumping Record NOV 19 2019
Form 4 TOWN OF NORTH ANDOVER
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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 Locatioe rout Righ of house, Left/Right rear of house, Left/right side of house, Left/
Right side of buiRiMg, Left/Right front of building, Left/Right rear of building, Under deck
Address c—
Cityffown State Zip Code
2. System Owner.
Name
Address(if different from location)
CitylTown State Kip Code
Telephone Number
B. Pumping Record c_
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1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Type of system: ❑ Cesspool(s) ptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes o If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System: c�
6. System Pumped By:
Neil.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Locati where contents-were disposed:
Lowell Waste Water
Sign aPH�ulwb� Date
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