HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 56 CRICKET LANE 9/21/2020 Commonwealth of Massachusetts
City/Town of RECEIVED
System Pumping Record
Form 4 SEP 212020
TOWN OF NORTH ANDOVER
DEP has provided this form for use=by local Boards of Health. Other forms ma*(MljtP0M"8tWMT
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 �/ ight e rd Ouse, Left/right sid of house, Left
Right side of building, Left/Right front of building, Left/Right rear of building nder deck-
Address
CfWrown State Zip Code
2. System Owner.
Name
Address(if different from location)
City/Town State ip Code
c
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Type of system: ❑ Cesspool(s) 0-9e-ptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter resent?p ❑ Yes [3-1do 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. Location where contents were disposed:
G L S Lowell Waste Water
4Sign �lNaul Date
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