HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 197 INGALLS STREET 5/18/2020 : Commonwealth of Massachusetts vZLECEIVE®
City/Town of
System Pumping Record MAY 18 2020
Form 4 TOWN OF NORTH ANDOVER
- 12�-171Trsr_NT
DEP has provided this form for usecby 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 t r;ni of hous�lldjrig,
ft/Right rear of house, Left/right side of house, Left
Right side of building, Left/R Left/Right rear of building, Under deck
address
C4y/rown State Zip Code
2. System Owner.
vv
Name
Address(if different from location)
Citynown �y,
State. � ��-use
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped:
Gallons
3. Type of system: ❑ Cesspool(s) ept c Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes o If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
6. System Pumped By:
Neil.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Ina
Company
7. 7GL
n ere contents-were disposed:
S. Lowell Waste Water
SignAWe it Haul Date
t5fbrm4.doc•06/03 System Pumping Record•Page 1 of 1