HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 859 WINTER STREET 8/24/2020 : Commonwealth of Massachusetts RECEIVED
City/'Town of AUG 2 4 2UZU
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
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; ont of house;Left/Right rear of house, Left/right side of house, Left
Right side of building, Left/Right fr oi`building, Left/Right rear of building, Under deck
Address �
�1 -
Cftyf r State Zip Code
2. System Owner.
Name'
Address(if different from location)
City/Town state Zip Code
`I 'T `f
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2- Quantity Pumped: Gallons
3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes a No If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
6. System Pumped By:
Neil.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Loca' here content&were disposed:
G L S' Lowell Waste Water
Sign acf KaulpwU Date
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