HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 19 CANDLESTICK ROAD 11/19/2020 : Commonwealth of Massachusetts RECEIVED
City/Town of NOV 19 Z020
System Pumping Record TOWN OF NORTH ANDOVER
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 hous"LeftLRigh "ear�of house Left/right side of house, Left
Right side of building, Left/Right front of building, Left/Rig rear of building, Under deck
Address
City/Town State Zip Code
2. System Owner.
Name* W
Address(if different from location)
Citynown State _` `�( -Zip Code
"C �
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 LSO If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System: � I
6. System Pumped By.-
Neil.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc-
Company
7. Location where contents,were disposed:
G L a-' Lowell Waste Water
Signitufe cfHaul Date
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