HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 42 JERAD PLACE 12/10/2019 Commonwealth of Massachusetts RECEIVED
City/Town of DEC 10 20 1
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 Locatio e 1 Ri n of house, Left/Right rear of house, Left/right side of house, Left/
Right side of bul g, Left ron o uilding, Left/Right rear of building, Under deck
Address
City/Town State Zip Code
2. System Owner. ` r
Name
Address(if different from location)
CiVrown State, `Is C /�p Code
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Type of system: ❑ Cesspool(s) a-S`eptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes LSO 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 re contents-were disposed:
G L S Lowell Waste Water
SignAtule Haut Date
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