HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 54 VEST WAY 12/10/2019 : Commonwealth of Massachusetts RECEIVED
City/Town of DEC 10 2019
System Pumping Record TOWN OF NORTH ANDOVEFt
r-
Form 4 HEALTH DEPARTMENT
DEP has provided this form for use=by local Boards of Health. Other forms may beused, 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 housL64/iRigi�r r of house Left/right side of house, Left
Right side of building, Left/Right front of building, Left/W-mar of building, Under deck
Address L� f F ,
CWTown State Zip Code
2. System Owner. V� �
Name
Address(if different from location)
City/Town State ���� arse
Telephone Number
B. Pumping Record
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 No If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of Systerq
6. System Pumped By:
Neil.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc-
Company
7. Location-where contents-were disposed:
�L S Lowell Waste Water
4KaA.
Signiftie 9t HaulwU Date
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