HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 55 LOST POND LANE 7/1/2020 Commonwealth of Massachusetts RECEIVE®
City/Town of
JUL o 12020
iq System Pumping Record
TOWN OF NORTH ANDOVER
Form 4
HEALTH DEPARTMENT
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 Locatio . Le Rig r nt of ho , Left/Right rear of house, Left/right side of house, Left
Right side of bull ng, Left/Right front of building, Left/Right rear of building, Under deck
Address —�-- ,
CWrown State Zip Code
2, System Owner.
Name 1
Address(if different from location)
Citylrown Stag �� ��Code
`-t
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: ` ✓���t/ 47,_ c-�
6. System Pumped By:
Neil.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc-
Company
7. Locatio ere contents-were disposed:
G L S. Lowell Waste Water
Sign a Haul Date
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