HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 285 REA STREET 7/2/2020 RECEIVED
: Commonwealth of Massachusetts JUL o 202
City/Town of
System Pumping Record TOWN OF NORTH ANDOVER
Y 9 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 Locationz9 �nt ouse, eft/Right rear of house, Left/right side of house, Left 1(
Right side of building, Left/mgnE frontof buildirig, Left/Right rear of building, Under deck
Address
City/Town State Zip Code
2. System Owner.
Name'
Address(if different from location)
City/Town State Zip 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? 0,,Ys ❑ No If yes, was it cleaned? - es No
5. Condition of System:
6. System Pumped By: r
Neil.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Locati a contents-were disposed:
_L S Lowell Waste Water
signiture f Hibuleru Date
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