HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 40 NORTH CROSS ROAD 2/24/2020 :�L\ Commonwealth of Massachusetts RECEIVED
City/Town of
System Pumping Record FEB 2 4 2020
Form 4 TOWN OF NORTH ANDOVER
HEALTH DEPAR7,?E",T
DEP has provided this form for us&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 forrim they use.The System Pumping Record must be submitted to
the local Board of Health or other approving authortfy.
A. Facflity Information ,—�----
1. System Location: Left/Right front of house, Le fight r ot�a f se;Left/right side of house, Left
Right side of building, Left/Right front of building, a Right rear of building, Under deck
Address
Citylrown State Zip Code
2: System Owner.
Name"
Address(if different from location)
GWTown /' Tip Code
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2 Quantity Pumped:
Gallons
3. Type of system: ❑ Cesspool(s) ptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes o If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
C LA -ems C'CCD SG�
6. System Pumped By:
Neil.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Ina
Company
7. Locati ere contents-were disposed:
G L S Lowell Waste Water
9. a ,/�
raOA-
SignWe qt Haul Date
t5fomi4.doc-06/03 System Pumping Record•Page 1 of 1