HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 42 JAY ROAD 12/10/2019 Commonwealth of Massachusetts RECEIVED
_ City/Town of DEC 10 2019
System Pumping Record TOWN OF NORTH ANDOVER
Form 4 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/right side of house, Left
Right side of building, Left/Right front of building, Left/Right rear of building, Under deck
Address (4
Cityfrown State Zip Code
2. System Owner.
Name
Address ff different from location)
Citylrown Stat� Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping Date - Qua Pumped: Gallons
3. Type of system: ❑ Cesspool(s) �S2
eptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes 0'10 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:
G L S Lowell Waste Water
qvta)).
Sign a I Haul Date
t5form4.doa 06/03 System Pumping Record•Page 1 of 1