HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 990 FOREST STREET 12/12/2019 Commonwealth of Massachusetts RECEIVED
W_ City/Town of
System Pumping Record DEC 1 � Z019
Form 4 TpYVN OF NORTH ANDovER
HEALTH DEPARTMENT
DEP has provided this form for use-by local Boards of Health. Other forms may *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: Le igh front of hou Left/Right rear of house, Left/right side of house, Left/
Right side of building, Le Rlg runt of building, Left/Right rear of building, Under deck
Address
CityRown Sfate Zip Code
2. System Owner.
Name'
Address(r different from location)
Citynown S �p C —�
Telephone Number
B. Pumping Record
1. Date of Pumping gate 2 Quantity Pumped:
Gallons
3. Type-of system: ❑ Cesspool(s) eptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes LSO If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
6. System Pumped By:
Neff Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Location—where contents-were disposed:
Lowell Waste Water
Sign&OeHauleiU Date
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