HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 133 COLONIAL AVENUE 11/19/2020 Commonwealth of MassachusettsMMEREMEMMM RECEIVED
City/Town of
System Pumping Record NOV 19 2020
Form 4 TOWN OF NORTH ANDOVER
HEAT!I nr nn T ENT
DEP has provided this form for use-by local Boards of Health. Other forms maybe 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, Left/§� �rqfhousLeft/right side of house, Left,/
Right side of building, Left/Right front of building, Left/Right rear of building, Under deck
Address
City'rr"n State Zip Code
2. System Owner.
Name.
Address(if different from location)
CityfTovm
Telephone Number
B. Pumping record
1. Date of Pumping gate 2. Quantify Pumped:
Gallons
3. Type-of system: ❑ Cesspool(s) ❑j-3 c Tank F1 Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes o If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System: r
6. System Pumped By:
Nell Bateson F5821
Name Vehicle License Number
Bateson Enterprises Ina
Company
7. Loca a contents-were disposed:
G L g1S. 1
Lowell Waste Water
Sign Date
t5form4.doc-06/03 System Pumping Record•Page 1 of 1