HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 23 TANGLEWOOD LANE 6/9/2020 Commonwealth of Massachusetts RECEIVED
_ City/Town of
.° System Pumping Record JUN 0 2020
Foram 4 TOWN OF NORTH ANDOVER
�••` 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 Locatio . Le Ri t front �' seLeft/Right rear of house, Left/right side of house, Left!
Right side of b ' g, Left/Rig t lding, Left/Right rear of building, Under deck
Address
City/Town state Zip Code
2. System Owner. ` ---�
Name
Address(i different from location)
Citylrown State , /�a -C��p Co
Telephone Number
B. Pumping Record
1. Date of Pumping pate 2. Quantity Pumped:
Gallons
3. Type of system: ❑ Cesspool(s) eptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes a4o If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System-
6. System Pumped By:
Neil.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc'
Company
7. Location where content were disposed:
G L S. Lowell Waste Water
Sign a Haul Date
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