HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 101 COLONIAL AVENUE 5/24/2021 Commonwealth of Massachusetts RECEMD
= City/Town of
System Pumping Record MAY 2 4 2021
Form 4 TOWN OF NORTH ANDOVER
HEAD TH 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.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: eft%ig rout o hous Left/Right rear of house, Left/right side of house, Left
Right side of bui( ' , Left ront of building, Left/Right rear of building, Under deck
Address
CitylTown v 1 (� �S•taatte=✓ Zip Code
2. System Owner.
Name
Address(if different from location)
Citynown State Zip Code
� c
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes al ,o If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of Syste!
YZ y ��
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 qflkaulevDate
t5form4.doc-06/03 System Pumping Record•Page 1 of 1