HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 101 SPRING HILL ROAD 4/1/2020 I
Commonwealth of Massachusetts RECEIVED
City/Town of
APR 12020
System Pumping Record -
TOWN OF NORTH ANDOVER
Form 4 HEALTH DEPARTMENT
DEP has provided this form for use-by local Boards of Health. Other forms maybe*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 forrh 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/Right rear of hous�/nigh Ide f hous Left/
Right side of building, Left/Right front of building, Left/Right rear of building, Under dec c
Address
Ctynown state Zip Code
2. System Owner.
Name'
Address(if different from location)
CitylTown Stater��r �� Zip(�uin
1
Telephone Number
.B. Pumping Record
1. Date of Pumping 2. Quantity Pumped:
Date
Gallons al ns III I
I
3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? es ❑ No If yes, was it cleaned? es ❑ No
5. Condition of System:
6. System Pumped By.
I
Neil.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Location where contents-were disposed:
'A L�ap Lowell Waste Water
'IM J- A
Signit4a fHaulWDate
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