HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 105 BROOKVIEW DRIVE 10/12/2021 Commonwealth of Massachusetts RECEIVED
City/Town of d
r 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 tame 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/klgrit rear of house: Left/right side of house, Left/
Right side of building, Left/Right front of building, Left/Right rear of building, Under deck
Address r
Cvrown State Zip Code
2. System Owner.
Name
Address(if different from location)
CiWown Stater Zip Code
Telephone Number
.B. Pumping record
1. Date of Pumping Date 2. Quantity Pumped: gallons
3. Type-of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes io / If yes, was it cleaned? ❑ Yes ❑ No
S. Condition of System:
6. System Pumped By:
(�e � F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. =LSj0P
re contents were disposed:
LoweWaste Water
Sign a Hauler' I V I, Date
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