HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 189 CARLTON LANE 8/10/2020 Commonwealth of Massachusetts
RECEIVED
_ 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 beused, but the
information must be substantially the same as that provided here. Before using.this form,check with your
focal 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 Locatio • it-nigh front of house,'Left/Right rear of house, Left/right side of house, Left
Right side of bull g;Left/RjgM-front-ofGuilding, Left/Right rear of building, Under deck
Address
Cityfrown State tip Code
2. System Owner.
Name
Address(d different from location)
CiWown StateCow- --� Zip Code
Telephone Number
B. Pumping record i
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 LSO If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System: 1
6. System Pumped By:
Neil.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc-
Company
7. Locati kHau
tents were disposed:
G L Lowell Waste Water
Sign a Date
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