HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 45 FOREST STREET 12/10/2019 : Commonwealth of Massachusetts RECEIVED
City/Town of
System Pumping Record DEC 10 2019
Form 4 TOWN OF NORTH ANDOVER
HEALTH DEPARTMENT
DEP has provided this form for us&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, Left/Right rear of house, Left/ st a of house,Left
Right side of building, Left/Right front of building, Left/Right rear of building, Under
Address �✓ � � � �_
CilyRown State Zip Code
2 System Owner.
Name"
Address(ir different from location)
CitYf row State�, �J, �` p Cade
Q
Telephone Number
B. Pumping Record
1. Date of Pumping Dates �2.�Qua'nfiPumped: Gallons
3. Type of system: ❑ Cesspool(s) k ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes o If yes,was it cleaned? ❑ Yes ❑ No
5. Condition of System:
S. System Pumped By:
Neil.Batesbn F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Location content&were disposed:
�L S Lowell Waste Water
Signitie cfHaulwUDate
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