HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 78 TANGLEWOOD LANE 1/14/2021 : Commonwealth of Massachusetts RECEIVED
City/Town of
System Pumping Record JAN 14 2021
-up
Form 4TOWN OF NORTH ANDOVER
HEALTH DEPARTMENT
DEP has provided this form for use-by local Boards of Health. Other forms maybe*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 tp_foyso, Left/Right rear of house, Left/right side of house, Left
Right side of building, Left/Right front of building, Left/Right rear of building, Under deck
Address
city/Town State Zip Code
2. System Owner:
Name'
Address(if different from location)
CityfTown stater Code
Telephone Number
B. Pumping Record
1. Date of Pumping Quanti Pumped:
Cate Quantity p Gallons
3. Type of system: ❑ Cesspool(s) [Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes 040 If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:��� tom, 4z5�4�
6. System Pumped By:
Neil.Batesbn F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Locqticinwhere contents were disposed:
�L S Lowell Waste Water
Sign aCfH&ulwu Date
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