HomeMy WebLinkAboutseptic tank - Septic Pumping Slip - 102 LOST POND LANE 8/4/2021 Commonwealth of Massachusetts RECEIVED
ulCity/Town of
System Pumping Record AUG 0 ? zo21
Form 4 TOWN OF NORTH ANDOVER
;. HEALTH DEPARTMENT
DEP has provided this form for use=by local Boards of Health. Other forms may beused, 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 rear of house, Left/right side of house, Left
Right side of building, Left/ Right font of building, Left/Right rear of building, Under deck
Address Da �Y 1 �04`1�Citylrown State Zip Code
2. System Owner.
Name
Address(if different from location)
City/Town stat Zi de
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2_ Q ntity Pumped: Gallons
3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes ff 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. Locatio a contents were disposed:
_L S. Lowell Waste Water
Signitufe Haul Date
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