HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 220 BOXFORD STREET 10/7/2020 Commonwealth of Massachusetts RECEIVED
_ City/Town of OCT 0 7 2020
Y° 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. Faci"Iity Information
1. System Location: Left/Right front of house, Left fight�!Ig- hr
Left/right side of house, Left
Right side of building, Left/Right front of buiidirig, building, Under deck
Address i
CfWrown State Zip Code
2. System Owner. _
Name
Address(if different from location)
ciWown State" �r 4 ,Zip Code
Telephone Number
B. Pumping Record C
1. Date of Pumping Date 2- Quantity Pumped:
Gallons
3. Type of system: ❑ Cesspool(s) 9-�6eptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes �a.�"� If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System: ���� r'� �✓���i ,,��c�����
6. System Pumped By:
Neil.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. L oca10 ere'contents"were disposed:
71L S Lowell Waste Water
ASigne� Haul Date
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