HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 270 SOUTH BRADFORD STREET 7/2/2020 : Commonwealth of Massachusetts RECEIVED
City/Town of JUL 01 2020
S stem Pam �n Record TOWN OF NORTH ANDOVER
Y N g 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 substantiW 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: Lefto§ ht front of house ft/Right rear of house, Left/right side of house, Left
Right side of building, Left ig ron o uiidirig, Left/Right rear of building, Under deck
Address
Cityfrown State Zip Code
2. System Owner.
Name
Address(if different from locafion)
CitylTown StateL� -00011
ode
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped:
Gallons
3. Type-of system: ❑ Cesspool(s) lc Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes Ly'No If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System: 49< �`- � C/L
-4t/VVk
6. System Pumped By:
Neil.Batesbn F5821
Name Vehicle t_icense Number
Bateson Enterprises Inc
Company
7. 7G�
ontents were disposed:
S Lowell Waste Water
Sign We fHauiwU Date
t5form4.doca 06103
System Pumping Record•Page 1 of 1