HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 56 CRICKET LANE 9/22/2021 Commonwealth of Massachusetts RECEIVED
_ . City/Town of SEP 2 2 20V
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 house/Right r ar of house /right side of house, Left/
Right side of building, Left/Right front of building, Left/RI uiiding, Under deck
Address
Citylrown State Zip Code
2. System Owner.
Name
Address(if different from location)
City/Town State- Z' Code
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped:
Gallons
3. Type of system: ❑ Cesspool(s) 318 ptic 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.Batesbn F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Location- ere c ontent&were disposed:
G L S. Lowell Waste Water
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Signitule fHauleVDate
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