HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 45 SHANNON LANE 3/16/2020 Commonwealth of Massachusetts RECEIVED
City/Town of
System Pumping Record MAR 16 2020
Form 4 TOWN OF NORTH ANDOVER
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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 ight fro�houseeft/Right rear of house, Left/right side of house, LeftRight side of building, Le figing, Left/Right rear of building, Under deck
Address
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City/Town State Zip Code
2. System Owner.
Name
Address(if different from location)
CitylTown State- _ Zip Code
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Telephone Number
B. 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 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 ere contents were disposed:
S. Lowell Waste Water
Signiftie cfHauleV Date
t5form4.dov 06/03 System Pumping Record•Page 1 of 1
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