HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 70 OGUNQUIT ROAD 6/9/2020 : Commonwealth of Massachusetts RECEIVED
_ City/Town of
System Pumping Record ouN o 0 2020
Form 4 TOWN OF NORTH ANDOVER
r••y pEALTH DEPARTMENT
DEP has provided this form for usez 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: Left/Right front of house, Left/Right rear of house, L i ht side o house,uo se, Left/
Right side of building, Left/Right front of building, Left/Right rear of building, Under e
Address
Citylrown y-- State Zip Code
2: System Owner.
Name \
Address(d different from location)
Cityfrown State Zi co
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? ❑ Yes If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
6. System Pumped By:
Neil.Bates7on F5821
Name Vehicle License Number
Bateson Enterprises Inc'
Company
7. L - "omwhere contents-were disposed:
G L S 1 i Lowell Waste Water
�Signkufe c9f Haul Date
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