HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 328 SUMMER STREET 4/28/2021 Commonwealth of Massachusetts P17"TIVED
City/Town of APR 2 8 2021
System Pumping Record
Form 4 TOWN OF NORTH ANDOVER
HEALTH DEPARTMENT
DEP has provided this form for us&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 Inform' ation
1. System Location: Left/Righ n o house a ight rear of house, Left/right side of house, Left/
Right side of building, Left/Right front of uildirig, Left/Right rear of building, Under deck
Address
citylrown State Zip Code
2. System Owner.
Name
Address(if different from location)
Cilylrown State I? Zip bode'
Telephone Number
.B. Pumping record
1. Date of Pumping Date 2. Quantity Pumped: Gauons
3. Type-of system: ❑ Cesspool(s) eptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes LSO If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of Sy
Oci
6. System Pumped By.
Neil.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Location where contents-were disposed:
_L Lowell Waste Water
Sign a"U, Date
t5formCdocr 06/03 System Pumping Record•Page 1 of 1