HomeMy WebLinkAboutseptic Tank - Septic Pumping Slip - 600 FOSTER STREET 5/18/2020 :-C\ Commonwealth of Massachusetts RECEIVED
City/Town of MAY 18 2020
System Pumping Record TOWN OF NORTH ANDUVER
Form 4 HEALTH DEPARTMENT
DEf 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 J Right rear of house, Left/right side of house, Left
Right side of building, Left/Right front of building, Left/Right rear of building, Under deck
Address C c� �
City/Town State Zip Code
2. System Owner. G�\�
Name.
Address(if different from locaffon)
CWTown Tin
Telephone Number
B. Pumping record
1. Date of Pumping Date 2_ Quantity Pumped:
Gallons
3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? es ❑ No If yes, was it cleaned? O'Yes ❑ No
5. Condition of Sys�(e `�(��-X�
6. System Pumped By:
Neil.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. 7G-
a contents-were disposed:
S. Lowell Waste Water
Sign a Piaui Date
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