HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 42 VEST WAY 8/10/2020 Commonwealth of Massachusetts RECESVEpA
_ City/Town of ug 10 20?f�
S stem Pum in Record TOWN OF NORTH ANDOVER
Y p g 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 house Left/Right rear of house, Left/right side of house, Left 1
Right side of building, Le Right fron uildirig, Left/Right rear of building, Under deck
Address r
CfWrown State Zip Code
2. System Owner. U
Name
Address(if different from location)
CityJTown State 7 Zi de
Telephone Number
B. Pumping Record
1. Date of Pumping pate 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.Batesbn F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Location where contents,were disposed:
.L S. Lowell Waste Water
Sign a Haul WU
Date
t5fnrm4.doc•06/03 System Pumping Record•Page 1 of 1
