HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 1659 OSGOOD STREET 9/2/2020 Commonwealth of Massachusetts RECEIVED
City/Town of SEP C 2 2010
System Pumping Record
TOWN OF NORTH ANDOVER
Form 4 HEALTH DEPARTMENT
DEP has provided this form for us&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: LeflIR ht front of house, Left/Right rear of house, Left/right side of house, Left
Right side of building, Left ig ront of building, Left/Right rear of building, Under deck
Address
Cityfrown v State Zip Code
2. System Owner.
Name
Address(if different from location)
Cityfrown State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping Date - G Quantity Pumped: "
Gallons
3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
,�Jo� -�
6. System Pumped By:
Neil.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Location where contents-were disposed:
Lowell Waste Water
Cj
vlaA.
SignAtute qt Haul Date
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