HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 4 CHRISTIAN WAY 6/9/2020 : Commonwealth of Massachusetts RECEIVED
City/Town of
System Pumping Record JUN 0 9 2020
Form 4 TOWN OF NORTH ANDOVER
- 7ME"T
CEP has provided this form for use-by local Boards of Health. Other forms may be'used,but the
information-must be substantiaffy 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 Locati Le gh r�ift/Right rear of house, Left/right side of house, Left
Right side of buillclihng, Left/Right front of building, Left/Right rear of building, Under deck
Address _
(` a C,_� w '
City/Town State Zip Code
2. System Owner. (�`
Name'
Address(if different from location)
City/Town
Telephone Number v
B. Pumping Record
J
1. Date of Pumping Date 2_ Quantity Pumped: Gallons
3. Type-of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes L 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. Locatimrtibere contents were disposed:
GWs. Lowell Waste Water
Sig Date
1:511ormCci -06/03 System Pumping Record•Page 1 of 1