HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 222 BRIDGES LANE 10/29/2020 .t-\ Commonwealth of Massachusetts RECEIVED
City/Town of OCT 2 9 2020
System Pumping Record TOWN OF NORTH ANDOVER
s..
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. Facility Information
1. System Location: Left/Right front of house, eft/Right rear of house, Left/right side of house, Left
Right side of building, Left/ ig t ront of ul ding, Left/Right rear of building, Under deck
Address
City/Town State Zip Code
2: System Owner.
Name
Address(if different from location)
City/Town State
Telephone Number
B. Pumping Record
1. Date of Pumping pate 2. Quantity Pumped: Gallons
3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System�Cx � ` v\
6. System Pumped By:
Neil.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc-
Company
7. Location ere contents were disposed:
Lowell Waste Water
Signitufe I Haul Date
t5form4.doca 06/03 System Pumping Record•Page 1 of 1