HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 261 REA STREET 2/24/2020 : Commonwealth of Massachusetts RECEIVED
City/Town of
W, System Pumping Record FEB 2 4 2020
Form 4 TOWN OF NORTH ANDOVER
HEALTH^EPARTMENT
DEP has provided this form for use-by local Boards of Health. Other forms may be Used,but the
m
information-must be substantially the sae 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 Locatiogh �Offfo—us—e,Left/Right rear of house, Left/right side of house, Left/
Right side of bu7 tn�, Left/ ldirig, Left/Right rear of building, Under deck
Address c C7 `
City/Town State Zip Code
2. System Owner.
Name'
Address(if different from location)
CWrown Z!Mo'z.
Telephone Number
B. Pumping Record
1. Date of Pumping - C� —a Da 2. Quantity Pumped:
Gallons
3. Type-of system: ❑ Cesspool(s) P<ptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes o if yes, was it cleaned? ❑ Yes ❑ No
5. Conditi of System:
6. System Pumped By:
Neil.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7.JG_
on tents-were disposed:
: Lowell Waste Water
Haul Date
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