HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 185 BRIDGES LANE 11/27/2019 Commonwealth of Massachusetts RECEIVE®
City/Town of NOV 2 7 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 house, Left/Right rear of house, Left Krlght side of hou eft
Right side of building, Left/Right front of building, Left/Right rear of building, Under deck
Address
./U. Al-A
City/rown State Zip Code
2. System Owner.
Name c
Address(if different from location)
CiWown State Zip Code
Telephone Number
B. Pumping Record
_ I
1. Date of Pumping I ),"I I 2 Quantity Pumped: \'
Date Gallons
3. Type of system: ❑ Cesspool(s) [3 Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes 0 No 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. Locatiog where contents were disposed:
G-L&P Lowell Waste Water
Sign a Hauf Date
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