HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 197 VEST WAY 11/23/2020 : Commonwealth of Massachusetts RECEIVED
City/Town Of NOV 2 3 2020
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 used,but the
information-must be substantiagy 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/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
City/row n State Zip Code. �1
2. System Owner.
Name. U
Address(if different from location)
CitylTown
Tele hone Number
B. Pumping record
IL)
1. Date of Pumping Date 2 Quantity Pumped:
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:
6. System Pumped By:
Neil.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Location where contents were disposed:
G L S. Lowell Waste Water
H)� /'C)
Sign a H�auwlwu Date
t5fbrm4.doa 06/03 System Pumping Record•Page 1 of 1