HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 40 GRANVILLE LANE 10/2/2020 RECEIVED
Commonwealth of Massachusetts
City/Town of
TOWN OF NORTH ANDOVM
_ 0
System Pumping Record HEALTH DEPARTMENT
Form 4
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, Right f o , Left/right side of house, Left
Right side of building, Left/Right front of building, Left/Right rear of building, Under deck
Address
Cityfrown State Zip Code
2. System Owner.
Name'
Address(if different from location)
CityfTown stater Zip Code
3
Telephone Number
B. Pumping [record
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Type of system: ❑ Cesspool(s) 0-15eptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes 2_Mo If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
to `y r-) t
6. System Pumped By:
Neil.Bates-on F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. LocaUm wbere contents-were disposed:
G Lowell Waste Water
Sign a Haul Date
t5fnrm4.doa 06/03 System Pumping Record•Page 1 of 1