HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 79 ROCKY BROOK ROAD 1/28/2020 RECEIVED
_ Commonwealth of Massachusetts JAN 2 8 2020
City ff own of TOWN OF NORTH ANDOVER
System Pumping Record HEALTH DEPARTMENT
Form 4
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 hous, Liftleg,
/ h id of house ,eftRight side of building, Left/Right front of building, Left/Right rear of Un er ec
Address �_
City/Town ( �— State 1, � Zip Code
2: System Owner.
Name
Address(if different from location)
City/Town State
Code _L
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped:
Gallons
3. Type of system: ❑ Cesspool(s) P-Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes ❑-'fio 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. Locatio here contents,were disposed:
G L S Lowell Waste Water
qSignAtuje Haul Date
15form4.doa 06/03 System Pumping Record•Page S of 1
