HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 173 BRIDGES LANE 7/2/2020 Commonwealth of Massachusetts RECEIVED
City/Town of JUL 0 12020
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 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 Location: Left/ h �oh;t
�rono
Left/Right rear of house, Left/right side of house, Left/
Right side of building, L lding, Left/Right rear of building, Under deck
Address
City/To" C State Zip Code
2. System Owner.
Name.
Address(if different from location)
CWTown Stet ��2,,,,Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping Date V2 Quantity Pumped:
Gallons
3. Type-of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes U440 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. Location-where contents-were disposed:
_L S Lowell Waste Water
Sign a qt-HauletU Dabs
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