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HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 40 SUGARCANE LANE 10/29/2020 .Y&\- Commonwealth of Massachusetts City/Town of RECEIVED System Pumping Record OCT 2 0 2020 Foinzn 4 TOWN OF NORTH ANDOVER HEALTH DEPARTMENT DEf has provided this form for use-.by local Boards of Health. Other forms may be'used,but the information-must be substantially the two 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: Le ight'front of hou Left/Right rear of house, Left/right side of house, Left Right side of building. Left Ig ront of building, Left/Right rear of building, Under deck Address �C) Citylrown State Zip Code 2. System Owner. Name' Address(if different front logfion) GtylTown .--���p ode 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 ©1q_0__ If yes, was 4t cleaned? ❑ Yes ❑ No 5. Condition of System: 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 /o Sign We Haul Date t5form4.docr 06/03 System Pumping Record•Page 1 of 1