HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 137 CHRISTIAN WAY 5/26/2020 Commonwealth of Massachusetts RECEIVED
City/Town of MAY 2 6 2020
N. System Pumping Record
Form 4 TOWN OF NORTH ANDOVER
s, HEALTH DEPARTMENT
DEP has provided this form for usez by local Boards of Health. Other forms maybe*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 Locatio . e / ig rout df house, eft/Right rear of house, Left/right side of house, Left
Right side of bui , Left/Right front of building, Left/Right rear of building, Under deck
Address
Ciwrown State Zip Code
2. System Owner.
Name'
Address(if different from location)
Citylrown State � /�/ V � Cede
C-/L
Telephone Number
B. Pumping record
1. Date of Pumping Date 2- Quantity Pumped: Gallons
3. Type of system: ❑ Cesspool(s) 0--Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes Leo If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System: n
6. System Pumped By:
Neil.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc-
Company
7. Location whera contents-were disposed:
Lowell Waste Water
Sign We 9t HlaulwU Date
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