HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 68 CRICKET LANE 12/10/2019 Commonwealth of Massachusetts RECEIVED
= City/Town of
System Pumping Record DEC 10 2019
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: Left/Right front of house, Left/Right rear of house, Left MqQht sidg—othouse, Left
Right side of building, Left/Right front of building, Left/Right rear of building, Under deck
Address c�
City/Town State Zip Code
2. System Owner.
Name
Address(f different from location)
Cityrrown Stale ZI C9da
SAS
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Type of system: ❑ Cesspool(s) La'Septic 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. Loca ontenta were disposed:
L
Lowell Waste Water
Sign a Haul Date _
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