HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 70 LOST POND LANE 5/18/2020 : Commonwealth of Massachusetts RECEIVED
City/Town of
W. System Pumping Record MAY 18 2020
Form 4 TOWN OF NORTH ANDOVER
HEALTH DEPARTMENT
DEP has provided this form for use-by local Boards of Health.Other forms may be bsed,but the
information must be substantially the same as that provided here. Before using Ahis 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 Inforlrrttation
1. System Location: Left/Right front of house, Left/ ht rear of hous , Left/right side of house, Left/
Right side of building, Left/Right front of buildirg, Left/Righ rear of building, Under deck
Address
yam,.
CRY/Town State Zip Code
2. System Owner. f ,
Name'
Address(if different from location)
CWTown S
r7`7a --G�s Zip'elj-C,I
Telephone Number
.B. Pumping Record
5--
I. Date of Pumping 2 Quantity Pumped:
Gallons
3. Type-of system: ❑ cesspool(s) ptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes a_110 If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
6. System Pumped By.
Neil.Batesbn F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Lo re contentewere disposed:
C�.L S: Lowell Waste Water
Sign aXHWJB���� Date
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