HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 50 JAY ROAD 12/10/2019 Commonwealth of Massachusetts RECEIVED
City/Town of DEC 10 2019
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 Information
1. System Location: Leftj Cic
ght front of house, Left/Right rear of house, Left/right side of house, Left/
Right side of building, Left/Right front of building, Left/Right rear of building, Under deck
Address
�k-
CitylTown State Zip code
2. System Owner.
Name
Address(if different from location)
City/Town State
Telephone Number
B. Pumping Record
1. Date of Pumping gate ;;eptic
Quantity P mped:
Gallons
3. Type of system: ❑ Cesspool(s) Tank El 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. Locatio contents were disposed:
S. Lowell Waste Water
'Signitufe qt Haul Date
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