HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 131 GRANVILLE LANE 10/5/2021 Commonwealth of Massachusetts RECEIVED
City/Town of OCT 0 5 2021
System Pumping Record TOWN OF NORTH ANDOVER
Form 4 HEALTH DEPARTMENT
DEP has provided this form for umby local Boards of Health. Other forms may *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 authorfty.
A. Facility Information
1. System Location: Left/Right front of house, left/Right rear of house, eft% side obuse,�kRight side of building, Left/Right front of building, Left/Right rear of building, Un r
Address P4
CityRown State Zip Code
2. System Owner.
Name G
Address(if different from location)
Telep one Number
B. Plumping Record
1. Date of Pumping Date 2 Quantity Pumped:
Gallons
3. Type-of system: ❑ Cesspool(s) tic Tank ❑ Tight Tank
❑ Other(describe): /
4. Effluent Tee Filter present? ❑ Yes ['W6 If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
6. System Pumped By:
Neil.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Lo . n ere contents-were disposed:
G_ S Lowell Waste Water
I CNN
OA 6
Sign aoaulw Date
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