HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 260 CANDLESTICK ROAD 7/8/2021 : Commonwealth of Massachusetts RECEIVED
_ City/Town of JUL 0 8 2021
System Pumping Record TOWN OF NORTH ANDOVER
Form 4 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 Location: Left/Right front of house, Left t� ht rear of house, Left/right side of house, Lgft/
Right side of building, Left/Right front of building, Left g rear of building, Under deck `'
Address
City/Town state Zip Code
2. System Owner: S�j
Name'
Address(if different from location)
Citylrown State -�� Code
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2- Quantity Pumped: Gallons
3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes a-No 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. Lo re contents,were disposed:
G L S Lowell Waste Water
Signitufe 9t HiauliiU Date
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