HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 11 BARCO LANE 8/4/2021 RECEIVED
Commonwealth of Massachusetts AUG 0 4 2021
City/Town of
TOWN OF NORTH ANDOVER
System Pumping Record HEALTH DEPARTMENT
Form 4
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/Right ear of house eft/right side of house, Left
Rig t side of building, Left/Right front of building, Left/Right:rear of building, Under deck
A Q y
Crtylrown State Zip Code
2. System 0 Owner.
Name
Address(if different from location)
Cityrrown S Zip Cade
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? ❑ Yeo If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System: C�C
i
6. System Pumped By:
Neil.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc-
Company
7. Location where contents were disposed:
Lowell Waste Water
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Signitute Haul Date
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