HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 41 CEDAR LANE 9/21/2020 : Commonwealth of Massachusetts RECEIVED
City/Town of
System Pumping Record SEP 21 2020
Form 4 TOWN OF NORTH ANDOVER
HEALTH DEPARTMENT
DEP has provided this form for use-by local Boards of Health. Other forms maybe 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 authorfty.
A. Facility Information
1. System Location: Left/Right front of hous Righ r -house I Left/right side of house, Left
Right side of building, Left/Right front of buiRdhfig, Left/Rlg rear of building, Under deck
Address
cj ( C
City/Town State Zip Code
2. System Owner.
Name'
Address(if different from location)
cityrrown State-
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped: Gauons
3. Type of system: ❑ Cesspool(s) tic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes M--No If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
6. System Pumped By.
Neil.Batesbn F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Locati a contents-were disposed:
_L S Lowell Waste Water
Sign a Haul Date
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