HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 121 OLD CART WAY 8/4/2021 Commonwealth of Massachusetts RECEIVED
= City/Town of aU�1 0
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System Pumping Record
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 Location: LeOh
front of house, Left/Right rear of house, Left/right side of house, Left
TV
ide of build' i ht fron of building, Left/Right rear of building, Under deck
Addr s,
!Town State Zip Code
2. qystem Owner.
Name'
Address(if different from location)
City/Town state �� ,An 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 No If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System- F}
6. System Pumped By:
Neil.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc-
Company
7. Location where contentry were disposed:
L S Lowell Waste Water
-diinitufe 9t Haul Date
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