HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 144 CRICKET LANE 10/5/2021 Commonwealth of Massachusetts RECEIVED
. City/Town of
System Pumping Record OCT 015, 202.1
Form 4 TOWN OF NORTH ANDOVER
r•w 11,.7_-.TH DEPARTti?E'T
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 Locatio(:Le:9 Righ roni off Fious eft/Right rear of house, Left/right side of house, Left
Right side of building, Left/Righ ron of building, Left/Right rear of building, Under deck
Address
Cit town State Zip Code
2. System Owner.
_ 50VI
Name
Address(if different from location)
CityfTown State Zip Code
Sow -
Telephone Number
B. Pumping record
1. Date of Pumping Date _ Quantity Pumped: Gallonsr 5�
3. Type of system: ElCesspool(s) Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes No 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 e contents were disposed:
G L S Lowell Waste Water
Signitule I HauleV Date
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