HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 50 FARNUM STREET 7/2/2020 Commonwealth of Massachusetts RECEIVED
_ City/Town of jUL 01 2020
System Pumping Record TOWN OF NORTH ANDOVER
Form 4 HEALTH DEPARTMENT
DEP has provided this form for usez 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/Right front of hous ft/ ightCeea— sous, Left/right side of house, Left
Right side of building, Left/Right front of buil ing, Left/Righ-rear of building, Under deck
Address _
City/Town State Zip Code
2. System Owner. � ,
Name'
Address(if different from location)
CitylTown State i 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 (-W---� If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
6. System Pumped By:
Neil.Batesbn F5821
Name Vehicle L►cense Number
Bateson Enterprises Inc-
Company
7. Locatt here contents-were disposed:
x'G,LS-P Lowell Waste Water
Signiftie cf Haul Date
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