HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 550 BOXFORD STREET 4/23/2020 ._ Commonwealth of Massachusetts RECEIVED
City/Town of APR 212020
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 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 LocatioF�Rig nt of lion Left/Right rear of house, Left/right side of house, Left/
Right side of bu ing, Left/Rtg front of building, Left/Right rear of building, Under deck
Address �-- �^ - s_ 4— n ,T „
CftYlrown State F1� Zip Code
2. System Owner.
Name'
Address(if different from location)
C4frown state`., � � �_4P Code
Telephone Number
B. Pumping record
1. Date of Pumping Date �2. Quanti Pumped: Gallons
3. Type-of system: ❑ Cesspool(s) tic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes o If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System: Jam(, /
pry /�
6. System Pumped By:
Neil.Batesbn F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Locati a contents were disposed:
Cam_ S Lowell Waste Water
c-IMSA.
Sign a Haul Date
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