HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 114 STONECLEAVE ROAD 11/30/2020 44- Commonwealth of Massachusetts RECEIVED
City/Town of NOV 3 0 2020
System Pumping Record TOWN OF NORTH ANDOVER
Form 4 HEALTH DEPARTMENT
I V.
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 bTh 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 fight rear of hous ;Left/right side of house, Left/
Right side of building, Left/Right front of building, Left/Right rear of building, Under deck
Address r/ `:S( �-� G� _cc- �
C#ydrown c '�[ state Zip Code
2. System Owner.
Name
Address(if different from location)
CitylTown J�Cf� ct
Telephone Number
B. Pumping record
1. Date of Pumping Date 2 Q ntity Pumped:
Gauons
3. Type-of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ No If yes,was it cleaned? Lis Ll No
5. Condition of System0�it C�j
6. System Pumped By:
Neil.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Ina
Company
7. Location w contents-were disposed:
e
_L S Lowell Waste Water
SignAWe it HhuleV Date
tftrm4.doc•06/03 System Pumping Record•Page 1 of 1