HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 120 LIBERTY STREET 7/1/2020 RECEIVED
Commonwealth of Massachusetts
City/Town of JUL. 01 2020
System Pumping Record TOWN OF NORTH ANDOVER
HEALTH DEPARTMENT
Form 4
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 Locatione ront of oous�Left/Right rear of house, Left/right side of house, Left/
Right side of buil mg, `Lefton of building, Left/Right rear of building, Under deck
Address 1`.��> ��1/�_�-�
QWrown State Zip Code
2. System Owner.
Name
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
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 Leo If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System: 62
Z
6. System Pumped By:
Neil.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc-
Company
7. Location where contents-were disposed:
G L�1 Lowell Waste Water
Sign a haul Date
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