HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 213 CARLTON LANE 8/4/2021 :�—L\ Commonwealth of Massachusetts RECEIVED
City/Town of
System Pumping Record AUG 0 4 2.021
Form 4 TOWN OF NORTH ANDOVER
HEALTH DEPARTM,ANT
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; Aight front of house, Left/Right rear of house, Left/right side of house, Left
jht ide of b 'Iding, Left/Right front of building, Left/Right rear of building, Under deck
City/rown State Zip Code
2. System Owner.
Name
Address(if different from location)
CitylTown State Z Code
Telephone Number
B. Pumping Record
� 21
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? 0-Yes ❑ No
5. Condition of System:
6. System Pumped By:
Neil.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc-
Company
7. Location vghere contents,were disposed:
'G L S Lowell Waste Water
SignitLie 9t Haul Date
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