HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 169 GRAY STREET 6/2/2021 Commonwealth of Massachusetts RECEIVED
City/Town of
System Pumping Record JuN 0 2 2021
Form 4 TOWN OF NORTH ANDOVER
HEALTH 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
focal 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 1 i 'egr of house, Left/right side of house, Left,/
Right side of building, Left/Right front of building, Left/Right re-ar 3Muilding, Under deck
Address
City/Town Site Zip Code
2. System Owner.
Name
Address(if different from location)
Cityfrown State Cede
Telephone Number
B. Pumping Record
�=�`f aviJ
1. Date of Pumping pate 2. Quantity Pumped: Gallons
3. Type of system: ❑ Cesspool(s) 0-136eptic Tank ❑ Tight Tank
❑ Other(describe): —
4. Effluent Tee Filter present? ❑ Yes Ito/'! If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
6. System Pumped By.,
Neil.Batesbn F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Location where contents were disposed:
ftHaul
Lowell Waste Water
Sign Date
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