HomeMy WebLinkAboutseptic tank - Septic Pumping Slip - 450 BOSTON STREET 6/9/2020 Commonwealth of Massachusetts RECEWED
Citylfown of
System Pumping Record JU 2020
Form 4 TOWN OF NORTH ANDovER
T,,^_a,nRTMENT
DEP has provided this form for use=by local Boards of Health. Other forms may beused, 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 housq�ldr I e ouse'Left
Right side of building, Left/Right front of building, Left/Right rear of bul mg, der�eek�
Address Ll ci��)
city/Town State Zip Code
2. System Owner. S�C�Jc)
Name
Address Cd different from location)
city/Town state zi
Telephone Number
B. Pumping Record ,
1. Date of Pumping Date 2- Quantity Pumped: Gallons
3. Type of system: ❑ Cesspool(s) epbc Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? a Yes ❑ No If yes, was it cleaned?
5. Condition of Syste
6. System Pumped By:
Neil.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Location where contente,were disposed:
_L Lowell Waste Water
SignAtufe qt HiaulerU Date
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