HomeMy WebLinkAboutSeptic Tank - Receipt - 116 CHRISTIAN WAY 11/23/2020 : Commonwealth of Massachusetts RECEIVED
City/Town of NOV 2 3 2020
System Pumping Record
Form 4 TOWN OF NORTH ANDOVER
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 house, Left/ ight rear of ho , Left/right side of house, Left/
Right side of building, Left/Right front of building, I_e /Right rear of building, Under deck
Address
City/Town state Zip Code
2. System Owner.
Name'
Address(if different from location)
Cit)fTown stater �-�_ s,�e
Telephone Number
B. Pumping Record
1. Date of Pumping Deb 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:
6. System Pumped By.
Neil.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Locatio here contentewere disposed:
_ S Lowell Waste Water
SigWeH-9 Date
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