HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 136 CARLTON LANE 4/30/2020 Commonwealth of Massachusetts RECEIVED
City/Town of APR 3 0 2020
System Pumping Record
Form 4 TOWN OF NORTH ANDOVER
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 forrim they use. The System Pumping Record must be submitted to
the local Board of Health or other approving authority.
A. Facility Information
1. System Locatio , eft R nt o house,Left/Right rear of house, Left/right side of house, Left
'Right side of bu ^', eft/�g uildlrig, Left/Right rear of building, Under deck
Address
City/Town State Zip Code
2. System Owner.
Name'
Address(if different from location)
CitylTown State Zip t le
Telephone Number
B. Pumping record
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 0_N0 If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System: �'`�✓�1,�� ���� �✓����'k.f"�—�
6. System Pumped By:
Neil.Bateson F5821
Name Vehicle Ltcense Number
Bateson Enterprises Inc
Company
7. Location whycontents-were disposed:
_L S Lowell Waste Water
Signitufe fH1,u1wUDate
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