HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 20 COLONIAL AVENUE 8/24/2020 ._ Commonwealth of Massachusetts RECEIVED
City/Town of r,u 2 4 2020
System Pumping Record TOWN OF NORTH ANDOVER
Form 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 autho ft.
A. Facility Information
1. System Locati 1* g front of hou , Left I Right rear of house, Left I right side of house, Left I
Right side of bu tng, Left/Right front of building, Left/Right rear of building, Under deck
Address
city/Town JCS State Zip Code
2. System Owner-
Noma'
Address(if different from location)
CWTown State r2 Tip Code
zip
Telephone Number
B. Pumping Record
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 0 No if yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
6. System Pumped By:
Neil.Bateson F5821
Name Vehicle Ltcense Number
Bateson Enterprises Inc
Company
7. Location where contents-were disposed:
G L S Lowell Waste Water
SignAWe qt HaulwU Date
t5form4.doc•06/03 System Pumping Record•Page 1 of 1