HomeMy WebLinkAboutSeptic tank - Septic Pumping Slip - 365 BOSTON STREET 11/19/2020 : Commonwealth of Massachusetts RECEIVED
W. City/Town of
System Pumping Record NOV 19 20Z0
Form 4 TOWN OE NORTH ANDOVER
HEALTH DEPARTMENT
DEP has provided this form for use-by local Boards of Health. Other forms may 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 'gh#iaj �fr�6ntof
ft/Right rear of house, Left/right side of house, Left/
Right side of building, Le building, Left/Right rear of building, Under deck
Address
cityrrown State Zip Code
2. System Owner. r^
Name' b
Address(ir different from location)
Citylrown State C Q"` Cod
Telephone Number
B. Pumping Record
1. Date of Pumping 2 Quantity Pumped:
Date Gallons
3. Type of system: ❑ Cesspool(s) eptic Tank ❑ Tight Tank
❑ Other(describe): ,/
4. Effluent Tee Filter present? a Yes 0 No If yes, was it cleaned? ` -Ygis ❑ No
5. Condition of System;
6. System Pumped By:
Neil.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Lo o where contents-were disposed:
G L S. Lowell Waste Water
Sign a Haul Date
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