HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 31 JAY ROAD 12/7/2020 Commonwealth of Massachusetts RECEIVED
City/Town of 2020
System Pumping Record DEC 0 7
Form 4 TOWN OF NORTH ANDOVER
D�PARTMW
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: Le ightfro--nt of hous ) Left/Right rear of house, Left/right side of house, Left
Right side of building, Le ig t fron of building, Left/Right rear of building, Under deck
Address
CiR own State Zip Code
2. System Owner.
Name*
Address(if different from location)
Cityfrown State ZIP Code
Telephone Number /
B. Pumping Record _
1. Date of Pumping Date 2. Quantity Pumped: Gans
3. Type of system: ❑ Cesspooi(s) Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes Ly nto 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. LocatipR where contenta were disposed-
G-L&P Lowell Waste Water
Signitufe crHaulerlf Date
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