HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 44 CRICKET LANE 10/5/2021 Commonwealth of Massachusetts � = ` '��®
City/Town of
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 Inform' ation
1. System Location: Left/Right front of house, Left�Right rear df house, Left/right side of house, Left
Right side of building, Left/Right front of building,Leff FUJ-Ff—rear—o�build'tng, Under deck
Address
Cityrrown State Zip Code
2. System Owner.
Name'
Address(if different from location)
Cityfrown Stater ` Zip Code
Telephone Number
.B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped: GaAons
3. Type of system: ❑ Cesspool(s) [a-Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? [ 'Yes ❑ No If yes, was it cleaned? D-Yes ❑ No
5. Condition of System:
6. System Pumped By:
F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Location where contentsrwere disposed:
Lowell Waste Water
Signitute cf Hbulwl Date
5form4.docr 06/03 System Pumping Record•Page 1 of i