HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 59 SUNSET ROCK ROAD 7/13/2020 Commonwealth of Massachusetts RECEIVED
= City/Town of
System Pumping Record JUL 13 ?� i
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 forrim 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 Riga di o house,'Left/right side of house, Left
Right side of building, Left/Right front of building, Left/Rig tig er-�i - ar of building, Under deck
Address �9 � \A� C��p
City/Town State V Zip code
2. System Owner. v.
Name
Address(f different from location)
CitylTown State ` _/`"[q C e
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 If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System: �-
6. System Pumped By:
Neil Bates-on F5821
Name Vehicle License Number
Bateson Enterprises Inc-
Company
7. Lofation-where contents were disposed:
G S. Lowell Waste Water
GC)
SigZ�-
a Haul elu
Date
t5form4.doc.-06/03 System Pumping Record•Page S of 1