HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 67 CRICKET LANE 1/13/2020 Commonwealth of Massachusetts RECEIVED
City/Town of JAN 13 2020
System Pumping Record
Form 4 TOWN OF NORTH ANDOVER
HEALTH DEPARTMENT
DEP has provided this form for useby local Boards of Health. Other forms may be*used,but the
information must be substantially the same as that provided here. Before using.this fbrm,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
City/Town State Zip Code
2: System Owner.
Name'
Address(if different from location)
CiWTown S Code
Telephone Number
6. 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 System:
6. System Pumped By:
Neil.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Location where contents-were disposed:
Lowell Waste Water
Sign We qt HauleiU Date
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