HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 30 EAST PASTURE CIRCLE 2/10/2020 44- Commonwealth of Massachusetts RECEIVEp
City/Town of
System Pumping Record FEB 10 2.OZC
Fotriln 4 TOWN OF NORTH ANDOVER
HEALTH DEPARTMENT
DEP has provided this form for use-by local Boards of Health. Other forms maybe*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,4(;'d nigh r 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
CityRom State Zip Code
2. System Owner.
Name'
Address(If different from location)
CityfTown
Telephone Number
B. Pumping Record
1. Date of Pumping Date ;�eptic
Quanti mped: Gallons
3. Type of system: ❑ Cesspool(s) 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. here contents-were disposed:
G L S Lowell Waste Water
Sign a qt Haut Mu
Date
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