HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 49 ORCHARD HILL ROAD 7/13/2020 Commonwealth of Massachusetts RECEIVED
City/Town of JUL 13 2 0?0
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 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 house Left/Right rear of house, Left/right side of house, Left
Right side of building, Left/Righ ro . of boil ng, Left/Right rear of building, Under deck
Address
Cityrrown State Zip Code
2. System Owner: � n
Name f
Address(if different from location)
Cityfrown State Zip e
Lf /
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Type of system: ❑ Cesspool(s) L ,Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes ❑ No If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of s m:
Z�k � V-\
6. System Pumped By:
Neil.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Locateswhere contents were disposed:
GG S Lowell Waste Water
Sign a Haul Date
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