HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 784 WINTER STREET 7/13/2020 : Commonwealth of Massachusetts RECEIVED
City/Town of JUL 13 2020
System Pumping Record
Form 4 TOWN OF NORTH ANDOVER
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 Location: Left ght front of Pious Left/Right rear of house, Left/right side of house, Left
Right side of building, Left/Right front of building, Left/Right rear of building, Under deck
Address �-7 W l ,� \ �--� .
C70from t State Zip Code
2. System Owner.
Name.
Address(if different from location)
CitylTown Stater Zip
� ode CD
Telephone Number �l
B. Pumping Record
�5',::� a
1. Date of Pumping �
P g Date 2- Quantity Pumped:
Gallons
3. Type of system: ❑ Cesspool(s) ptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes D No If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
6. System Pumped By:
Neil.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7joc keretentawere disposed:
Lowell Waste Water
Date
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