HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 85 CARLTON LANE 8/24/2020 RECEIVED
Commonwealth of Massachusetts AUG 2 4 2020
_ C+ity/Town of
System Pumping Record TOWN OF NORTH ANDOVER
Y p g 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 hous�ig rear o hous , Left/right side of house, Left
Right side of building, Left/Right front of building, Left/ g rear of building, Under deck
Address
City/Town State Zip Code
2. System Owner.
Name
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped:
Gallons
3. Type of system: ❑ Cesspool(s) 4'S116/ptic Tank ❑ Tight Tank
❑ Other(describe): /
4. Effluent Tee Filter present? ❑ Yes Et4O 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 a contents were disposed:
G l S. Lowed Waste Water
SignAtule cf Haul Date
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