HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 59 NORTH CROSS ROAD 7/1/2020 .Commonwealth of Massachusetts RECEIVED
City/Town of
System Pumping Record JUL 01 2020
Form 4 TOWN OF NORTH ANDOVER
HEALTH DEPARTMENT
DEP has provided this form for use-by local Boards of Health. Other forms may be*used,but the
information-must be substandW 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 house, Le rear of house eft/right side of house, Left
Right side of building, Left/Right front of building, Left/Righ rear d building, Under deck
Address
CityRown State Zip Code
2. System Owner.
4z--� 06talv\-
Name'
Address(if different from location)
CitylTawn State/ C rZLp Code
Telephone Number
B. Pumping Record
0
1. Date of Pumping Date 2. Quantity Pumped:
Gallons3. Type-of system: ❑ Cesspool(s) Erte-ptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System: ..�f� � �
:� c4�zz_
6. System Pumped By:
Neil.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. LocaflorLwhere contents-were disposed:
G"P \S. Lowell Waste Water
Sign Data
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