HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 221 CAMPBELL ROAD 4/30/2020 Commonwealth of Massachusetts RECEIVED
= City/Town of
System Pumping Record APR 3 0 2020
Form 4 TOWN OF NORTH ANDOVER
�• ! -^-'TH 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 Location: Left/Right front of house_ , Left/Right rear of house, Left/right side of house, Left
Right side of building, Le ig ron o uilding, Left/Right rear of building, Under deck
Address
Cityfrown A State Zip Code
2, System Owner.
Name
Address(if different from location)
Cityfrown Zip
e
Te4hone�Number
B. Pumping Record
tk -,�)-7- ( -
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Type of system: ❑ Cesspool(s) eptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes Leo If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System: IN
L-,� A,�,CJ
6. System Pumped By:
Neil Batesbn F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Location where contents,were disposed:
Lowell Waste Water
LfignffeDate
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