HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 74 STONECLEAVE ROAD 9/21/2020 Commonwealth of Massachusetts RECEIVED
City/Town of SEP 212020
System Pumping Record TOWN OF NORTH ANDOVER
Form 4 HEALTH DEPARTMENT
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DEP has provided this form for usez 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/bight rear of hour, Left/right side of house, Left
Right side of building, Left/Right front of building, Left/Right rear of building, Under deck
Address
City/Town State Zip Code
2. System Owner.
Name
Address(if different from location)
City/Town S� Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Type of system: ❑ Cesspool(s) (-beptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
6. System Pumped By:
Neil.Bates-on F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Loca. here contents were disposed:
G L S. Lowell Waste Water
Sign a Haul Date
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