HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 554 FOSTER STREET 7/13/2020 Commonwealth of Massachusetts RECEIVE®
City/Town of JUL 13 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
focal 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/right side of house, Left
Right side of building, Left/Right front of building, Left/Right rear bAbuilding, Under deck
Address `
CiWrown State Zip Code
2. System Owner.
Name �c
Address(if different from location)
Cityfrown State
Telephone Number
.B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped:
Gallons
3. Type of system: ❑ Cesspool(s) Ea-Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑- Yes ❑ No If yes, was it cleaned? E-fifes-❑ No
5. Condition of System:
6. System Pumped By:
Neil.Bateson F5821
Name Vehicle license Number
Bateson Enterprises Inc
Company
7. Location wherg contents were disposed:
�L S Lowell Waste Water
A��SigZne Haul Data
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