HomeMy WebLinkAbout- Septic Pumping Slip - 769 FOREST STREET 10/31/2018 Commonwealth of Massachusetts
RECEME'',,' D
City/Town of
0("Iff,f 113 "12 0 18
System Pumpino Record
Form 4 TOWN OF NORM ANDOVER
HEALTH DS-)ARI-MENT
DEP has provided this form for usemby local Boards of Wealth. Other forms maybe'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 forrin they use.The System Pumping Record must be submitted to
the local Board of Health or other approving authority.
----------A. Factlity InforMatilon
1. System Location: Left/Right front of house, Le rea of h 1 v Left/right side of house, Left/
Right side of building, Left/Right fr6nt of building, Left Right rear of building, Under deck
Address
ctlyfrown State Zip Code
2. System Owner. VJ
Address(if different from location)
City/Town State-
telephone Number
.B. Pumping Record
1. Date of PumpingDate 2. Quantity Pumped: Gallons
3. TypeV system., Cesspool(s) Septic Tank Tight Tank
0 Other(describe):
4. Effluent Tee Filter present.? Yes o If yes, was it cleaned? Ej Yes ❑ No
5. Condition of System:
6. System Pumped By:
Nei[BatesTon F5821
Name Vehicle Utcanse Number
Bateson Enterprises Inc-
Company
7. Location ]were contents were disposed:
L Lowell Waste Water
Sign Haul au Date
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