HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 258 BRIDGES LANE 8/24/2020 RECEIVED
: Commonwealth of Massachusetts AUG
City/Town of 2 q 2020
TOWN OF NORTH ANDOVER
System Pumping Record HEALTH DEPARTMENT
Form 4
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 �ofhouseLeft/right side o_f house, LeftRight side of bul�ding, Left/Right front of building, Leuildin nder
Addressg,5 o Bf
City/Town State Zip Code
2. System Owner.
Name
Address(if different from location)
CityJTown _ Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping Cate 2. Quantity Pumped:
Gallons
3. Type-of system: ❑ Cesspool(s) ptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? Yes ❑'No If yes, was it cleaned? D-Yft--n No
5. Condition Ceps IJ
1�
6. System Pumped By:
Neil.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Location where contents were disposed:
L S Lowell Waste Water
"--M a- A.
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