HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 300 FOSTER STREET 6/9/2020 Commonwealth of Massachusetts RECEIVED
City/Town of JUN 0 9 2020
System Pumping Record
TOWN OF NORTH ANDOVER
Form 4
HEALTH DEPARTMENT
U91 .
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/Right front of house, Left I Right rear of house, Left/right side of house, Left
Right side of building, Left/Right front of building, Left/Right rear of building, Under deck
Address ` �j
CWTown State Zip Code
2. System Owner.
Name
Address(if different from location)
Cityrrown Stat - _
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2Quantity Pumped: Gallons
3. Type of system: ❑ Cesspool(s) [ Sep.Q�tic Tank ❑ Tight Tank
❑J-tither(describe):
4. Effluent Tee Filter present? ❑ Yes ❑ No 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. Lo ere contents-were disposed:
G L S. Lowell Waste Water
Sign a Haul Date
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