HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 72 PADDOCK LANE 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 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 house, Left/Right rear of house,(�aft/ 'g side of house, eft
Right side of building, Left/Right front of building, Left/Right rear of bu Ing. Un
Address
Q Town i State Zip Code
2. System Owner.
Name
Address(if different from location)
Citylrown
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 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. Location where contents-were disposed:
.L Lowell Waste Water
Sign e Haul Date
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