HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 182 LACY STREET 8/24/2020 : Commonwealth of Massachusetts RECEIVED
City/Town of
System Pumping Record AUG 2 4 20?0
Form 4
TOWN OF NORTH ANDOVER
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 forrh 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 4 S* h4tfront&ron
use Left/Right rear of house, Left/right side of house, LeftRight side of building, Le t uildirig, Left/Right rear of building, Under deck
Address f �Q G h L-�
Cityrrowo ! (� State Zip Code
2. System Owner.
Name" L
Address(if different from location)
CWTown State V( 3
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2 Quantity Pumped: Gallons
3. Type of system: ❑ Cesspool($) ptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System: Kki y _
6. System Pumped By:
Neil.Batesbn F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. L contents-were disposed:
G L S: Lowell Waste Water
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Sign a Haul D�
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