HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 265 SUMMER STREET 8/4/2021 Commonwealth of Massachusetts RECEIVED
City/Town of AUG 0 4 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 forrh 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/ . ht nt of house, Left/Right rear of house, Left/right side of house, Left/
RiQ ht side of bu' ing, Left/Right o of building, Left/Right rear of building, Under deck
Addtess
1144
C itylrown State Zip Code
2. Sys Owner.
Name
Address(if different from location)
Citylrown Stat Zip Code
r/- 3 2F' i F �7
elephone Number
B. Pumping record
Date of Pumping 1. a p g date 2. Quantity Pumped:
Gallons
3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes 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. Location where contents-were disposed:
G L Lowell Waste Water
SignAtufe I HaulerU pate
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