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HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 25 SUNSET ROCK ROAD 4/1/2020 RECEIVED .-C\- Commonwealth of Massachusetts APR 12020 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�ftight rear of houso, Left/right side of house, Left Right side of building, Left/Right front of building, Left-!Right rear of building, Under deck AddressKza City/Town State Zip Code 2. System Owner. Name Address(if different from location) Cityffown State ©'� r q Code ` � C��\�\ Telephone Number ' B. Pumping record 1. Date of Pumping Date ��e Quan ' Pumped: Gallons 3. Type of system: ❑ Cesspool(s) tic Tank ❑ Tight Tank ❑ Other(describe): 4. Effluent Tee Filter present? ❑ Yes Ly No 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. Lo ' n_wh contenta were disposed: G L S. Lowell Waste Water Sign a Haul Date t5form4.doa•06/03 System Pumping Record•Page 1 of 1