HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 427 SUMMER STREET 6/2/2021 4— Commonwealth of Massachusetts DECEIVED
City/Town of
System Pumping Record JUN 0 7.02�
Form 4 iOWN OF NORTH ANDOVER
N�ALTH 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: Left/Right front of house(
gh r o hous , Left/right side of house, Left
Right side of building, Left/Right front of building, Left/Right rear of building, Under deck
Address
L4
a � -
Citylrown State Zip Code
2. System Owner.
Name'
Address(if different from location)
CityJTown state L/- 3 Sz Code
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2 Quantity Pumped:
rations
3. Type-of system: ❑ Cesspool(s) ptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes D ivo 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. io
ratL-
contents were disposed:
S Lowell Waste Water
`1�aSA- — (Dn:!
Sign We(fl-laulev Date
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