HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 270 SOUTH BRADFORD STREET 6/14/2021 Commonwealth of Massachusetts RECEIVED
_ City/Town of
System Pumping Record JUN 14 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
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 Locatio eft/ igh r t of house, Left/Right rear of house, Left/right side of house, Left/
Right side of bui ' g, Left/Right ron o uildirig, Left/Right rear of building, Under deck
Address --) �yl - � � A�( ,G /
Cityrrown State Zip Code
2. System Owner.
Name
Address(if different from location)
Cityfrown State Z'ip Code
'-7
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2- Quantity Pumped: Gallons
3. Type of system: ❑ Cesspool(s) 0- tic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes LSO 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. Locatiomwhere contents-were disposed:
Lowell Waste Water
Signitufe cf HguleV Date
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