HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 64 FOREST STREET 7/1/2020 : Commonwealth of Massachusetts RECEIVED
City/Town of
System Pumping Record JUL 01 2020
Fps 4TOWN OF NORTH ANDUVER
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•reRig nt of h , Left/Right rear of house, Left/right side of house, LeftRight side of but�d , eft) Rig ron o build'mg, Left/Right rear of building, Under deck
Address C ` _
Citylrown � state Zip Code
2. System Owner. LQ-o
Name'
Address(if different from location)
cityrrown
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped:
Gallons
3. Type-of system: ❑ Cesspool(s) eptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? es ❑ No If yes, was it cleaned? ❑ No
5. Condition of System:
6. Sysigm Pumped By:
Neil.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. L7S-L
contents-were disposed:
aer Lowell Waste Water
Sign aqHaweiU
Date
t5fbrm4.doa 06/03 System Pumping Record•Page 1 of 1