HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 61 GRANVILLE LANE 6/9/2020 Commonwealth of Massachusetts RECEIVED
City/Town of SUN p 9 2020
System Pumping Record
Form 4 TOWN OF NORTH ANDOVEFt HEALTH DEPARTMENT
DEP 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• Righ nt of h use ft/Right rear of house, Left/right side of house, Left
Right side of bulgy , Left/ udding, Left/Right rear of building, Under deck
Address
(0c
City/Town (/ State Zip Code
2. System Owner.
Name'
Address(y different from location)
Citylroum State/ - � � -3 Zip Cade,
Telephone Number
B. 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? esA If yes, was it cleaned? ❑)fes ❑ No
5. Condition of System•
6. System Pumped By:
Neil.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Ina
Company
7. Location where contents were disposed:
_L S Lowell Waste Water
Signkje fHiulmUpa{e
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