HomeMy WebLinkAboutSeptic tank - Septic Pumping Slip - 125 BRIDGES LANE 12/7/2020 Commonwealth of Massachusetts RECOVED
City/Town of 2020
System Pumping Record DEc 0 7
Form 4 TOWN OF NORTH ANDOVER
r• ur_ i TH DEPARTMENT
DEP has provided this form for use=by local Boards of Health. Other forms may beused, 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/Right rear of houseff�hig side of hous Left 1
Right side of building, Left/Right front of building, Left I Right rear of building, Under eck
Address r
City/Town State Z4 code
2. System Owner.
Name
Address(if different from location)
CitylTown State �� Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping Date ;�SepticTank
Q antity Pumped: Gallons
3. Type of system: ❑ Cesspool(s) ❑ 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
Sign a Haul Date
t5form4.doca 06/03 System Pumping Record•Page 1 of 1