HomeMy WebLinkAboutSeptic Pumping Slip - 770 FOREST STREET 6/5/2017Commonwealth of Massachusetts
City/Town of
yste pi ec rd
Form 4
TOWN OF NAPETH ANDOVER
HEALTH DEPARTMENT
DEP has provided this form for usetle 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 igt1t of hou_si, Left/ Right rear of house, Left / right side of house, Left /
Right side of bui , Left / of building, Left / Right rear cif building, Under deck
Address
City/Town
2. System Owner:
Address (if different from location)
City/Town
LJJ
piing
1. Date of Pumping
c
3. Type of system:
Other (describe):
4. Effluent Tee Filter present? 0 Ye
' 5. Condition of System:
System Pumped By:
Nell Bateson
Name
Bateson Enterprises Inc
State ct)
Telephone Number
Date 2. Quantity Pumped:
Gallons
Cesspool(s) Eg---s; Tank El Tight Tank
LL
Company
7. Lo tionhere contents were disposed:
S Lowell Waste Water
If yes, was it cleaned? 0 Yes 0 No
F5821
Vehicle License Number
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