HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 218 LACY STREET 9/21/2020 _ Commonwealth of Massachusetts REcavEo
City/Town of 5EP 212020
System Pumping Record TOWN OF NORTH ANDOVER
Form 4 HEALTH DEPARTMENT
DEP has provided this form for use=by local Boards of Health. Other forms may beused, 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/Right rear of house, Left/right side of house, Left/
Right s-Ye of building, Left/Right front of building, Left/Right rear of building, Under deck
Ad ess
�`%.r
City/Town State Zip Code
2. System Owner.
, n
Name
Address(if different from location)
Cityrrown State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Type of system: ❑ Cesspool(s) [] Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes Q No If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
A- Si-4tJ
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
Sign acqtt PHaulg���� Date
t5form4.doc•06/03 System Pumping Record•Page 1 of 1