HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 15 NORTH CROSS ROAD 8/10/2020 ._ Commonwealth of Massachusetts RECEIVED
MONESEMONS
City/Town of AUG 10 2020
System Pumping Record TOWN OF NORTH ANDOVER
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 L / 'g us side of ho Left
Right side of building, Left/Right front of building, Left/Right rear of building, Un erUr
Address / ,S—
City/Town State Zip Code
2. System Owner.
Name"
Address(if different from location)
CWTown Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping Date2. Quantity Pumped: Gallons
3. Type-of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes Olwo If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System: y�
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
SignAWe 9t HaulerU Date
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