HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 33 SHERWOOD DRIVE 8/4/2021 Commonwealth of Massachusetts RECEIVED
City/Town of
l- P System Pumping Record AUG 0 2021
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: Left ' �of Left/Right rear of house, Left/right side of house, LeftRight side of budding, Left idirig, Left/Right rear of building, Under deck
Address
City/rown `Lam- swe Zip Code
2. System Owner. r _ 0 V-,
Name
Address(W different from location)
City/Town state Lt�f t�' cXip code
Telephone Number `C
B. Pumping Record T7
1. Date of Pumping Date ;;eptic
Qu' - Pumped:
Gallons
3. Type-of system: ❑ Cesspool(s) Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes alqO 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 a contents were disposed:
G L S Lowell Waste Water
Sign We 9f HbuleV Date
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