HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 208 CARLTON LANE 8/24/2020 ..�C\ Commonwealth of Massachusetts RECEIVED
City/Town of
System Pumping Record Aug 2 4 2020
Form 4 TOWN OF NORTH ANDOVER
HEALTH DEPARTMENT
DEf has provided this form for use-by local Boards of Health. Other forms maybe*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, Le t rear of house,�Lef-/right side of house, Left
Right side of building, Left/Right front of building, Left/Rig ar of building, Under deck
Address r
My/rown State Zip Code
2. System Owner.
Name'
Address(if different from location)
citynTown state
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped:
Gallons
3. Type-of system: ❑ Cesspool(s) 0-8 ptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes Ld'No If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
U
6. System Pumped By:
Neil.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Location re contents were disposed:
G L S ` Lowell Waste Water
(___M
Sign aCfHaLdervDate
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