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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 t5form4.doa 06/03 System Pumping Record•Page 1 of 1