HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 280 CANDLESTICK ROAD 3/16/2020 ..� Commonwealth of Massachusetts RECEIVED
City/Town of MAR 16 2020
System Pumping Record TOWN OF NORTH ANDOVER
Form 4 HEALTH DEPARTMENT
DEP has provided this form for useby local Boards of Health. Other forms may be used,but the
information must be substantiaffy 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/ ht front of;hou , Left/Right rear of house, Left/right side of house, Left/
Right side of building, Left/Right frof building, Left/Right rear of building, Under deck
Address
City/ro" State Zip code
2. System Owner.
Name
Address(f different from location)
citylTown _Z4;-Code
Telephone Number
B. Pumping Record
1. Date of Pumping 2. Quantity Pumped:
Gallons
3. Type-of system: ❑ Cesspool(s) ptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes E1,td6__ If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of Syst
6. System Pumped By:
Neil.Bateson F5821
Name Vehicle License Number
_Bateson Enterprises Inc
Company
7. contents-were disposed:
rL S. Lowell Waste Water
Sign a Haul Date
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