HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 1 SCOTT CIRCLE 8/16/2021 _ Commonwealth of Massachusetts RECEIVED
City/Town of AUG 16 ?021
System Pumping Record TOWN OF NORTH ANDOVER
Form 4 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/Right front of housePinag/,
ig rear .�ar
se eft/right side of house, Left
Right side of building, Left/Right front of bueft/ g of building, Under deck
Address t
Citylrown State Zip Code
2. System Owner.
Name
Address(if different from location)
Citylrown Stag r7✓ Zip�de
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Type of system: ❑ Cesspool(s) eptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes LSO If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
6. System Pumped By:
Neil.Bates-on F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Location w contents-were disposed:
G L S Q Lowell Waste Water
Sign a Haul Date
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