HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 91 CROSSBOW LANE 10/29/2020 Commonwealth of Massachusetts RECEIVED
City/Town of
System Pumping Record OCT 2 9 2020
Form 4 TOWN OF NORTH ANDOVER
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 foram,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, Left/right side of house, Left
Right side of building, Left/ Right front of building, Left/Right rear of building, Under deck
Address C- ( �
City/Town State Zip Code
2. System Owner.
Name
Address(if different from location)
City/Town State i
�� P �D
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 No 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. LocafiQtL�nchere contents-were disposed:
LG_LSJV Lowell Waste Water
SignAtufe ctHlauleUDate
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