HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 50 FARNUM STREET 10/12/2021 Commonwealth of Massaohusefts RECEIVED
City/Town of
f System Pumping Record o-:T I
Form 4 ToWN OF NORTH ANDOVER
,TH 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,'Right e of hous Left/right side of house, Left/
Right side of building, Left/Right front of building, Left/Right rear of building, Under deck
Address S—d ij
C'Wrown State Zip Code
2. System Owner.
Name
Address(if different from location)
City/Town Stater l� Code
Telephone Number
.B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Type of system: ❑ Cesspool(s) [3—Sep ctt Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes [�PdcS If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
6. System Pumped W.
"�. F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Location where contente were disposed:
L S Lowell Waste Water
FI—OD.
Sign a H9ulei Date
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