HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 50 ROCKY BROOK ROAD 7/2/2020 : Commonwealth of Massachusetts RECEIVED
City/Town of JUL 0 12020
System Pumping Record TOWN OF NORTH ANDOVER
Form 4 HEALTH DEPARTMENT
DEf has provided this form for use-by local Boards of Health. Other forms maybe*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: Left/Right front of house, Left I Right rear of house, Left/ side of hous Left/
Right side of building, Left/Right front of building, Left/Right rear of building, Under e
Address
city/Town ` �z State j Zip Code
2. System Owner.
Name.
Address(if different from location)
CiWTown Stater:�� Code
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 LLJ1W0 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. Locaton. �contents-were disposed:
L'Sp Lowell Waste Water
Sign a Haul p
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