HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 65 SUGARCANE LANE 11/23/2020 : Commonwealth of Massachusetts RECEIVED
City/Town of
System Pumping Record Nov 23 ZG2o
Form 4 TOWN OF NORTH ANDOVER
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/ �1 , 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
Cityrrown State Zip Code
2. System Owner. e�f��
Name
Address(if different from location)
CitylTown S`at e/j
Telephone Number P�
B. Pumping Record
Cy��g
1. Date of Pumping Date 2. Quantity Pumped: S
Gallons
3. Type of system: ❑ Cesspool(s) tic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes to If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
6. System Pumped By:
Neil.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Loch' re contents-were disposed:
L S Lowell Waste Water
(,Jff 0--A. B06Z_Izll�
Sign AQeHaut er Data
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