HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 66 JAY ROAD 3/10/2021 : Commonwealth of Massachusetts RECEIVED
ity/Town of MAR 10 2021
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 Ahis 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 house, Left/right side of house, Left
Right side of building, Left/Right front of building, Left/Right rear of building, Under deck
Address
cWrown state Zip Code
2. System Owner. 11
l V-
Name'
Address(if different from location)
CitylTown State _ Zip Code
Telephone Number
B. Pumping record
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Type of system: ❑ Cesspool(s) eptic Tank ❑ 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 contenta were disposed:
,,-G-jL'S-P Lowell Waste Water
Signitufe 9t Haul Date
t5fnrm4.doc•06/03 System Pumping Record•Page 1 of 1