HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 35 TIFFANY LANE 9/21/2020 Commonwealth of Massachusetts RECEIVED
City/Town of SEP 21 2020
System Pumping Record
Form 4 TOWN OF NORTH ANDOVER
�- 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: Le jdfk front of house eft/Right rear of house, Left/right side of house, Left 1
Right side of building, i ding, Left/Right rear of building, Under deck
Address
City/Town State Zip Code
2: System Owner.
Name
Address(if different from location)
Civrown State Zip Code
c->
61c,,
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Type of system: ❑ Cesspool(s) tic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes ❑-ilo If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of stem: 1
6. System Pumped By:
Neil.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc-
Company
7. Lo o contents were disposed:
G L S-JQ Lowell Waste Water
Signitute 9t Hauler Date
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