HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 88 PHEASANT BROOK ROAD 6/9/2020 : Commonwealth of Massachusetts RECEIVED
City/Town of
System Pumping Record SUN 0 -9 2020
Form 4 TOWN OF NORTH ANDOVER
DEf 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: Left/Right front of house, Left 'ght rear of house eft/right side of house, Left,/
Right side of building, Left/Right front of buildirg, a fight rear building, Under deck
Address
City/Town State Zip Code
2. System Owner.
Name'
Address(if different from location)
CitylTown Zip Code
c
Telephone
Number
.B. Pumping Record
1. Date of Pumping gate 2. Quantity Pumped:
Gallons
3. Type of system: ❑ Cesspool(s) [-Se(�c Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes � If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System: / 0 � C
6. System Pumped By:
Neil.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Ina
Company
7. Lo a contents-were disposed:
G L Lowell Waste Water 1
LOA. �
Signitie it HauleifDate
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