HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 370 SUMMER STREET 8/16/2021 Commonwealth of Massachusetts RECEIVED
City/Town of
System Pumping Record ' 16 2021
Form 4 f NORTH ANDOVER
. PARTMEW
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 house, Left eft/right side of house, Left
Right side of building, Left/Right front of building, Left/Right rear of building, Under deck
Address V VAM
City/Town �—i State /�/ Zip Code
2. System Owner. �(J�/�(/I't✓
Name
Address(if different from location)
CitylTown State Zip Co P,
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 No If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System: �-
r �
6. System Pumped By:
Neil.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Location re contents-were disposed:
_L S. Lowell Waste Water
Sign a Haul Date
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