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HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 11 BARCO LANE 7/13/2020 Commonwealth of Massachusetts RECEIVED City/Town of JUL 13 2021,J System Pumping Record TOWN OF NORTH ANDOVER HEALTH DEPARTMENT Form 4 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 hous , Le g=eaf-66ouse, Left/right side of house, Left Right side of building, Left/Right front of bul ing, Lefr of building, Under deck Address Citylrown State Zip Code 2. System Owner p t -Q� Name U �l Address(if different from location) Cityffown Stat Code Telephone Number B. Pumping Record 1. Date of Pumping Date 2. Quantity Pumped: Gallons 3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Other(describe): 4. Effluent Tee Filter present? ❑ Yes 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 7. Location where contents,were disposed: G L S. Lowell Waste Water Aigna Haul Date t5form4.docr 06/03 System Pumping Record•Page 1 of 1