HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 307 REA STREET 7/13/2020 Commonwealth of Massachusetts RECEIVED
of
System Pumping Record JUL 13 2020
Form 4 TOWN OF NORTH ANDOVER
HEALTH DEPARTMENT
DEf has provided this form for use-by local Boards of Health. Other forms maybe*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 authortty.
A. Facility Information
1. System Location: Left ht front of ho Left/Right rear of house, Left/right side of house, Left
Right side of building, Left/Rig front of building, Left/Right rear of building, Under deck
Address
City/Town State Zip Code
2. System Owner. 1 -
Name
Address(if different from location)
CitylTown 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? ❑ Yes 01, If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
6. System Pumped By:
Neil.Batesbn F5821
Name Vehicle License Number
Bateson Enterprises Ina
Company
7. Loc_ ere contents-were disposed:
G L S Lowell Waste Water
- �-D,=
e Haul Date
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