HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 165 FOREST STREET 6/9/2020 : Commonwealth of Massachusetts RECEIVED
City/Town of JUN 0 g 2020
System Pumping Record TOWN OF NORTH ANDOVER
Form 4 HEALTH DEPARTMENT
DEP has provided this form for use-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/ ht front o h use,�e /Right rear of house, Left/right side of house, Left/
Right side of building, Left/Right front or building, Left/Right rear of building, Under deck
Address
City/rown ( State Zip Code
2. System Owner.
Name'
Address(if different from location)
C4itown State Zi Cod
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped:
Gallons
3. Type-of system: ❑ Cesspool(s) pis Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes [j'>To__ 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. Locatio wh1-1 ere contents-were disposed:
G L S Lowell Waste Water
Sign a9r haul Date
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