HomeMy WebLinkAboutseptic tank - Septic Pumping Slip - 184 CARLTON LANE 11/27/2019 : Commonwealth of Massachusetts RECEIVED
City/Town of NOV 2 7 2019
System Pumping Record TOWN OF NORTH ANDOVER
Form 4 HEALTH DEPARTMENT
DEP has provided this form for useby 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, lg r of house eft ous , e
Right side of budding, Left/Right front of bull mng, Left/Right rear building, Uncle c
Address c �-
Cdy/rown State Zip Code
2 System Owner.
Name"
Address(if different from lopfion)
Cityfrown State��
Telephone Number
B. Pumping Record
Cs� -Cq
1. Date of Pumping Date 2. Quantity Pumped:
Gallons
3. Type-of system: ❑ Cesspool(s) eptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes o If yes,was it cleaned? ❑ Yes ❑ No
5. Condition of System:
6. System Pumped By:
Neil.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Lo contents-were disposed:
G L S Lowell Waste Water
Sign We CfHawwuDate
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