HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 353 BOXFORD STREET 6/9/2020 Commonwealth of Massachusetts
City/Town of RECEIVED
System Pumping Record SUN 0 0 2020
Form 4 TOWN OF NORTH ANDOVER
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DEP has provided this form for use=by Iota(Boards of Health. &er form H DEPART""
ma."
y 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 Left/right side of house, Left
Right side of building, Left/ Right front of buildin -Left f rear 63 building, Under deck
Address
City/Town State Zip Code
2. System Owner.
Name
Address(if different from location)
City/Town State C % /j
Q
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 a_No 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. Lo ere contents-were disposed:
G L Lowed Waste Water
SignAqe Haul Date
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