HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 488 SHARPNERS POND ROAD 11/30/2020 Commonwealth of Massachusetts
• City/Town of RECEIVED
System Pumping Record Nov 3 0 2020
Form 4 TOWN OF NORTH ANDOVER
�•' HEA)_TH D P T T
DEP has provided this form for use-by local Boards of Health. Other forms may used,b&Yi
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 I Right rear of hous , e g Ide of hK'i , Left
Right side of building, Left/Right front of building, Left/Right rear o of Un er
Address A
City/Town State Zip Code
2. System Owner.
Name
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
Ly-
1. Date of Pumping Date 2. Quantity Pumped: Gallons
i
3. Type of system: ❑ Cesspool(s) [D-Sei-ptic 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. Location where contents were disposed:
Lowell Waste Water
h -�
tSignAtufe f Haul Date
t5f6rm4.doc•06/03 System Pumping Record•Page t of 1