HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 162 GRAY STREET 6/9/2020 : Commonwealth of Massachusetts rrED
City/Town of
System Pumping Record 0UN 0 9 2020
Form 4 TOWN Or NORTH ANDOVER
Hz. ^''ARTMENT
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: Le i hXt!,:nt of house, Left/Right rear of house, Left/right side of house, Left/
Right side of building, Left/ t ron of building, Left/Right rear of building, Under deck
Address (6 f'� — �l`�- ` `/
Cityrrown State Zip Code
2. System Owner.
Name'
Address(Ir different from locafion)
own sta��C -r?
Telephone Number
B. Pumping Record
S,--DQ
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: �-e/C./
6. System Pumped By:
Neil Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Lo re contents-were disposed:
G L S Lowell Waste Water
,---1VW.A, - - :�a —Q� C_�> -
SignAhle ctHaulerUDate
tftrm .doa 06/03 System Pumping Record•Page 1 of 1