HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 70 LOST POND LANE 10/5/2021 Commonwealth of Massachusetts RECEIVED
City/Town of o 'C 1
System Pumping Record
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 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, Left ht rear of ho Left/right side of house, Left
Right side of building, Left/Right front of building, Left/Righ rear of building, Under deck
Address 1-1
cWrown State Zip Code
2. System Owner.
Name
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
C -'off-a, -t
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Type of system: ❑ Cesspool(s) eptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes 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.jSigne
re contents were disposed:
. Lowell Waste Water
Haul Date
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