HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 102 SPRING HILL ROAD 11/30/2020 Commonwealth of Massachusetts
RECEIVED
City/Town of NOV 3 0 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 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 CRight rear of house' Left/right side of house, Left
Right side of building, Left/Right front of building, Leff7l�ig t r�Ti ear of building, Under deck
Address
Cityfrown State Zip Code
2. System Owner.
Name
Address(if different from location)
Citylrown State r��-,v `f g Code
Telephone Number
B. Pumping Record
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? ❑-�S ❑ No
5. Condition of System nt11
6. System Pumped By:
Neil Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Lo where contents,were disposed:
G L S. Lowell Waste Water
Sign a Haul Date
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