HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 41 BEAVER BROOK ROAD 4/28/2021 Commonwealth of Massachusetts RECEIVED
_ City/Town of APR 2 8 2021
° System Pumping Record TOWN OF NORTH ANDOVER
HEALTH DEPARTMEN7
Form 4
DEP has Provided this form for usez 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 forrh 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 hous , L / g side of house Left
Right side of building, Left/Right front of building, Left/Right rear of ul mg, Under ec
Address
QWrown State Zip Code
2. System Owner.
Name
Address(if different from location)
cityffown State c 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 alwo 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 content%were disposed:
MeHiaaul
S. Lowell Waste Water
SiMUDate
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