HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 96 FARNUM STREET 4/1/2020 RECEIVED
: Commonwealth of Massachusetts APR 2020
City/Town of -
TOWN OF NORTH ANDOVER
System Pumping Record HEALTH DEPARTMENT
Form 4
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/Right front of house, Left ' t rear_pf ho_u�a'Left/right side of house, Left
Right side of building, Left/Right front of building, Left/Right rear of building, Under deck
Address
CWTown State Zip Code
2. System Owner.
Name
Address(if different from location)
CitylTown Star
i e
Telephone Number
B. Pumping Recor,,,-,,-
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 a No If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System, P
CJ
6. System Pumped By:
Neil.Bates-on F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Locati er ontents were disposed:
_L S. Lowell Waste Water
SignAtule Haut Date
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