HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 485 FOSTER STREET 8/10/2020 Commonwealth of Massachusetts RECEIVED
City/Town of 1 a loz0
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/Right front of housek Left/Right rear of house;Left/right side of house, Left 1
Right side of building, Left/Right front of building, Left TM-9htrearbf building, Under deck
Address / �, -""'—' y, �
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City/Town State Zip Code
2: System Owner.
Name
Address(if different from location)
CitylTown State Zip Code
0 &�? >0
Telephone Number
13. Pumping Record
1. Date of Pumping � ��✓��2_ Quan Pumped:
Date fi p Gallons
3. Type of system: ❑ Cesspool(s) eptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes 0'No If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
6. System Pumped By:
Neil.Batesbn F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Lo where contents were disposed:
G L S j Lowell Waste Water
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SignAtufe c9f Haul DD a
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