HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 2050 TURNPIKE STREET 10/2/2020 : Commonwealth of Massachusetts RECEIVED
_ City/Town of OCT --2 Z020
e 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,(*Righ ea(of house eft/right side of house, Left 1
Right side of building, Left/Right front of building, Left/Right rear of building, Under deck
Address
City/Town State Zip Code
2. System Owner.
-�C1v1
Name'
Address(if different from location)
CityfTown State],,_Zipl Code
Telephone Number
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 If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
V\-
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
Signkute 9t HaulerU Date
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