HomeMy WebLinkAboutseptic tank - Septic Pumping Slip - 399 SUMMER STREET 6/2/2021 Commonwealth of Massachusetts RECEIVED
City/Town of JU(v 0 2 2021
System Pumping Record
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
local Board of Health to determine the forrim 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/ h�" front of house, eft/Right rear of house, Left/right side of house, Left
Right side of building, Left/Right fron o uildirig, Left/Right rear of building, Under deck
Address
�-t
City/Town State Zip Code
2. System Owner:
Name
Address(if different from location)
city/Town Stater C Z. Code
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2- Quantity Pumped: Gallons
3. Type of system: ❑ Cesspool(s) ptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ 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. Location where contents-were disposed:
.r
_L S Lowell Waste Water
Siq4tule I HaulwU Date
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