HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 357 REA STREET 7/13/2020 Commonwealth of Massachusetts RECEIVED
_ City/Town of JUL 13 2020
System Pumping Record TOWN OF NORTH ANDUVER
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�fefU- rig side of house, Left
Right side of building, Left/Right front of building, Left/Right rear of building, Under deck
Address
Cityrrown State Zip Cods
2. System Owner.
Name
Address(if different from location)
CitylTown State "e
Telephone Number
6. Pumping Record � L
1. Date of Pumping Dade 2. Quantity Pumped: Gallons
3. Type of system: ❑ Cesspool(s) eptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes a-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. where contents-were disposed:
7G_'rLSQ,/ Lowell Waste Water
Signkula 9t HgulwU Data
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