HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 1491 TURNPIKE STREET 6/14/2021 Commonwealth of Massachusefts RECEIVED
_ City/Town of JUN 14 2021
System Pumping Record TOWN OF NORTH ANDOVER
Form 4 HEALTH DEPARTMENT
DEP has provided this form for uset by local Boards of Health. Other forms may beused, 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, Left/Right rear of house, LeftT—ag ciside o ouse Left 1
Right side of building, Left/Right front of building, Left/Right rear of building, Under 6-6 — -F
Address / p 1, c —TT J �r I
��'( 7
CWrown state Zip Code
2 System Owner.
Name
Address(if different from location)
CityfTown Stat ZiQ Code
Mom" '�D--q a 5
Telephone Number
B. Pumping Record -71
_
1. Date of Pumping Date L 2- Quantity Pumped:
Gallons
3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes tom' No If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System: U-&.1 - \ —
6. System Pumped By:
Neil.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc-
Company
7. Location w contents,were disposed:
l
_L$. Lowell Waste Water
Signihie CtHtlulwDate
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