HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 96 SUGARCANE LANE 5/18/2020 x. Commonwealth of Massachusetts
City/Town of MAY 18 2020
h. System Pumping Record TOWN OF NORTH ANDOVER
Form 4 HEALTH DEPARTMENT
DEP has provided this form for use-by local Boards of Health.Other forms may 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.
Q. Facility Information
1. System Location: Left/RigKfront of douse, ft/Right rear of house, Left/right side of house, Left/
Right side of building, Left/Right ron i ding, Left/Right rear of building, Under deck
Address
Owrown State Zip Code
2. System Owner.
Name
Address(if different from location)
Cit)frown }
Telephone Number
13. 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 a No If yes,was it cleaned? ❑ Yes ❑ No
5. Condition of System: P-7cv-(al
6. System Pumped By:
Neil.Batesbrl F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Loca. e contents-were disposed:
//G,LSQ Lowell Waste Water
1-fYfaj)Y_
Sign we 9f Haulwj Date
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