HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 550 BOXFORD STREET 5/24/2021 Commonwealth of Massachusetts
EQ
= City/Town of
System Pumping Record MAY 2 4 2021
Form 4 TOWN OF NORTH ANDOVER
� • "' `,'TH DEPARTMEN
DEP has provided this form for use=by local Boards of Health. Other forms maybe'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 house, Left/right side of house, Left
Right side of building, Left/Right front of building, Left/Right rear of building, Under deck
Address
C"rtylr'own State Zip Code
2. System Owner � � QV\T�
Name"
Address(if different from location)
CityfTown State _r,Zip_Co
Telephone Number
B. Pumping Record
�✓
1. Date of Pumping pate 2. Quantity Pumped: Gallons
3. Type of system: ❑ Cesspool(s) eptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? El Yes o 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. Locatio a content&were disposed:
Lowell Waste Water
SWigna Haut Date
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