HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 78 LACY STREET 10/29/2020 Commonwealth of Massachusetts RECEIVED
City/Town of OCT 2 9 2020
System Pumping Record
Form 4 TOWN OF NORTH ANDOVER
REA1 TH 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 Locatio eft/;Rig fron of house, Left/Right rear of house, Left/right side of house, Left
Right side of bu , Left/Right front of building, Left/Right rear of building, Under deck
Address
Citylrown State Zip Code
2. System Owner.
Name
Address(if different from location)
CityfTown State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2• Quantity Pumped: `
GaIIORS
3. Type of system: ❑ Cesspool(s) .r(,�" tic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes o 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. rG-
tio a contents were disposed:
L S. Lowell Waste Water ( `
Sign a Haut Date
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