HomeMy WebLinkAboutSeptic Pumping Slip - 1551 OSGOOD STREET 9/7/2017 Commonwealth of Massachusetts
RECEIVED
Cit�/Town of .
° System Pumping-Record
Poral! 4 TOWN OF FORTH ANDOVER
HEALTH DEPARTMENT
DEP ha's provided this form'for use-by local Boards of Health. Other form's 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.Tire System Pumping Record must be submitted f0
the local Board of Health or other approving authority.
A. Facility. InforMation .
1. System Location: Left/Right front of House Left I Right rear of house, Left/right side of house, Leff I
Right side of building, Left/Righo uildiri Left/Right rear of building, Under deck
Address � � °)�... ""'�� "`�.5�'-�•S
City/Town State Zip Code
2. System Owner.
Name'
Address(if different from location)
City/Town ' St ate.
F J F6z
C
Telephone Number
' B i
j
r
. _ d
. Pumping record
1. Crate of PumpingDate �• Quantity Pumped:
Gallons
3. Type-of system: ® Cesspool(s) eptic Tank E] Tight Tank
® Other(describe):
4. Effluent Tee Filter present? ® Yes a 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. Loca' vi a contents were disposed:
C 1.S: Lowell Waste Water
1 !7
Signitu a OW—arV Date
1
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