HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 15 BRADFORD STREET 9/7/2021 : Commonwealth of Massachusetts RECEIVED
City/Town of
System Pumping Record sEP o 7 2021
Form 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 substantialiy 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, I(Rig Mig
r of house Left/right side of house, Left
Right side of building, Left/Right front of building, Left building, Under deck
Address
City/Town State Zip Code
2. System Owner. Ajjc—A�,
Name'
Address(of different from location)
CWrown State Zi Cod
�-� s.^
Telephon—e Number
B. Pumping Record
1. Date of Pumping Dal 2 Quantity Pumped:
Gallons
3. Type-of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank
❑ Other(describe): /
4. Effluent Tee Filter present? ❑ Yes ❑ O If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System: ,� / J��vl � 4MA ZZ
6. System Pumped By:
Neil.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Location Where contents were disposed:
_L S Lowell Waste Water 1
1vjA
Signitje qt Haul HaulwU DaTe-
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