HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 150 CHRISTIAN WAY 5/17/2021 Commonwealth of Massachusetts RECEIVED
_ City/Town of MAY 17 2021
System Pumping Record TOWN OF NORTH ANDOVER
Form 4 HEALTH DEPARTMEl'
r
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 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-ig nt of house Left/Right rear of house, Left/right side of house, Left
Right side of buil ing, Left/Right fron uildirig, Left/Right rear of building, Under deck
Address � �D (� c�
CitylTown State ` Zip Code
2. System Owner.
Name
Address(if different from location)
Citylrown State. Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Type of system: ❑ Cesspool(s) [a-Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes 0-ICo— 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 contents-were disposed:
S� Lowell Waste Water
Signitute 9f HaulerU Date
t5fbrm4.doc-06/03 System Pumping Record•Page 1 of 1