HomeMy WebLinkAboutSeptic Tank and Washer Dry Well - Septic Pumping Slip - 204 MILL ROAD 4/23/2020 : Commonwealth of Massachusetts RECEIVED
City/Town of
System Pumping Record APR 21 2020
Form 4 TOWN OF NORTH ANDOVER
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 hou ft% 'g rear of o su Left/right side of house, Left
Right side of building, Left/Right front ofeft of building, Under deck
Address
cityRown State Zip Code
2. System Owner.
Name
Address(if different from location)
Citylrown
Telephone Number 1 Z
B. Pumping record
1. Date of Pumping gate 2 Quantity Pumped: Gahlons
3. Type of ystem: ❑ Cesspool(s) ptic T,(a/nk Tight Tank
Other(describe):
4. Effluent Tee Filter present? ❑ Yes o If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of s
_ �_76FA
6. System Pumped By:
Neil.Batesbn F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. 7G�
contents-were disposed:
S Lowell Waste Water
S4ne Haul pate
tftrm4.doc•06/03 System Pumping Record•Page 1 of 1