HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 337 PLEASANT STREET 5/17/2021 :jL Commonwealth of Massachusetts RECEIVED
_ • City/Town of MAY 17 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 beused, 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/Right front of house, Left/Right rear of housq"teft righ side of ho su a Left 1
Right side of building, Left!Right front of building, Left/Right rear of buV=6-g-, Under deck --
address
Citylrown State l Zip Code
2. System Owner.
Name
Address(►f different from location)
CitytTown state- z' 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 ' 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. Lo where contents-were disposed:
G L S-JQ Lowell Waste Water
1-4 A O- A.
-,
Signitufe 9f Haulej Date
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