HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 337 SUMMER STREET 10/2/2020 : Commonwealth of Massachusetts RECEIVED
City/Town of OCT -2 202o
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: Rig nt of h '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
�t l un, wiref *-Jaxed
City/Town state Zip Code
2. System Owner.
Name
Address(of different from location)
Cit awn state Tip Code
7 S I 471E R?7
Telephone Number
B. Pumping Record
1. Date of Pumping Date '2 Quantity Pumped: Gallons
l ��---
3. Type-of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes 040 If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
6. System Pumped By:
Neil.Bateson F5821
Name l Vehicle License Number
Bateson Enterprises Ina
Company
7. Location where contents-were disposed,
L S Lowell Waste Water
--MaS- A. -
S _j 4 - 1r)
Sig a Fi�ul Date
151orm4.doc•06/03
System Pumping Record•Page 1 of 1