HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 350 BERRY STREET 11/19/2020 : Commonwealth of Massachusetts RECEIVED
_ City/Town of NOV 1 9 2020
System Pumping Record
TOWN OF NORTH ANDOVER
Form 4
�. HEAJH DEPARTMENT
DEP has provided this form for use=by local Boards of Health. Other forms may beused, 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 forrh 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
City/Town State Zip Cone
2. System Owner.
Name
Address(if different from location)
City/Town State�
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped:
Gallons
3. Type of system: ❑ Cesspool(s) Ic 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.Batesan F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Location where-contents-were disposed:
G L S. Lowell Waste Water
Sign a Haul Date
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