HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 130 CHRISTIAN WAY 11/27/2019 : Commonwealth of Massachusetts RECEIVE®
= City/Town of NOV 2 7 201
System Pumping Record
Form 4 TOWN OF NORTH ANDOVER
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 Informatiioon� _
1. System Location: Left/rdig_ ront of lid, Left/Right rear of house, Left/right side of house, Left 1
Right side of building, Left/Right front of building, Left/Right rear of building, Under deck
Address F
City/Town State T— Zip Code
2. System Owner.
Name
Address(if different from location)
Cityfrown -&Code
Telephone Number l
B. Pumping Record tc
1. Date of Pumping Date 2- 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: ,
6. System Pumped By:
Neil.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Location wham contents were disposed:
.L S Lowell Waste Water
9&SA.
Signjqe 9t HaulerU Date
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