HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 209 BRIDGES LANE 11/23/2020 :�L\ Commonwealth of Massachusetts RECEIVED
City/Town of NOV 2 3 ZG?U
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 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/ gh rear of house eft/right side of house, Left
Right side of building, Left/Right front of building, Le g rear of building, Under deck
Address
City/Town State Zip Code
2. System Owner.
Name
Address(if different from location)
Cityrrown State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping Datea an 2 entity Pumped: S�
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:
Qtmc
6. System Pumped By:
Neil.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Location where contents-were disposed:
<GL'$: Lowell Waste Water
Sign aqtHtkWS0 Date
l51orm4.doc•06/03 System Pumping Record•Page 1 of 1
