HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 481 REA STREET 9/21/2020 : Commonwealth of Massachusetts RECEIVED
City/Town of SEP 21 2020
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 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/Right rear of house, Left/right side of house, Left/
Right side of building, Left/Right front of building, Left/Right rear of building, Under deck
Address
is
City/Town State Zip Code
2. System Owner.
Name
Address(if different from location)
CitylTown Zip Code
Telephone Number c3"�
B. Pumping record
1. Date of Pumping Date 2. Quantity Pumped:
Gallons
3. Type-of system: ❑ Cesspool(s) eptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes Ly'No if yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
1
6. System Pumped By:
Neil.Batesbn F5821
Name Vehicle License Number
Bateson Enterprises Ina
Company
7. Location where contents-were disposed:
S Lowell Waste Water
SigOne lhul Data
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