HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 425 BOXFORD STREET 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'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 ont of ho , Left/Right rear of house, Left/right side of house, Left
Right side of bu ing, Left/Right front of building, Left/Right rear of building, Under deck
Address
City/Town State Zip Code
Z. System Owner.
Name
Address(if different from location)
CityfTawn
Telephone Number
.B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped:
Gallons
3. Type-of system: ❑ Cesspool(s) L-Septi Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes awo- If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System: � -Lk,
6. System Pumped By:
Neil.Batesbn F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Location wheiv content, were disposed:
G L S Lowell Waste Water
�O -- � �
Sign We cfHaulwUDate
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