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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, � ��, <, Z�4- -, /<j�� 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 k- SignAtufe c9f Haul DD a t5form4.doc,06/03 System Pumping Record•Page 1 of 1