HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 235 OLD CART WAY 9/7/2021 : Commonwealth of Massachusetts RECEIVED
City/Town of
System Pumping Record SEP 0 7 2021
Fonn 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/Right front of house, Le ear of hou eft/right side of house, Left
Right side of building, Left/Right front of building, Left/Rig ar of building, Under deck
Address ra
Cityfrown �L) (` state Zip Code
2: System Owner.
Name
Address(if different from location)
City/Town State/a � �� � �Zip Cod
Telephone Number
B. Pumping record
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Type-of system: ❑ Cesspool(s) 0,teptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
6. System Pumped By:
Neil.Batesbn F5821
Name Vehicle License Number
Bateson_ Enterprises Ina
Company
7. Locati re contents-were disposed:
aLS-P Lowell Waste Water
Sign a H&ul Date
15form4.doc•0W03 System Pumping Record•Page 1 of 1