HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 31 SUGARCANE LANE 3/16/2020 : Commonwealth of Massachusetts RECEIVED
City/Town of MAR 16 2020
System Pumping Record
Form 4 TOWN OF NORTH ANDUVER
HEALTH DEPARTMENT
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/ g t ront of hous , Left/Right rear of house, Left/right side of house, Left
Right side of building, L lght front of building, Left/Right rear of building, Under deck
Address
cItyrrown State rip code
2. System owner:
Name'
Address(if different from location)
Citynown State e
Telephone Number
.B. Pumping Record _
1. Date of Pumping Dam 2. Quantity Pumped:
Gallons
3. Type-of system: ❑ Cesspool(s) eptic 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. ZSigne
a contents-were disposed:
S. Lowell Waste Water
l Date
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