HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 30 SUNSET ROCK ROAD 10/2/2020 A�- Commonwealth of Massachusetts RECEIVED
City/Town of
TOWN OF NORTH ANDOVER
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 Ahis 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, Left/Right rear of house side of hou Left
Right side of building, Left/Right front of building, Left/Right rear of building, n c
Address,7-
CitylTown State Zip Code
2. System Owner.
Name
Address(if different from location)
City/Town Sate i�Code
Telephone Number
B. Pumping record
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Type of system: ❑ Cesspool(s) ptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System-
6. System Pumped By:
Neil.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc'
Company
7. Locatim where contents were disposed:
Lowell Waste Water
Signitule 9t Haul Date
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