HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 193 FOSTER STREET 8/24/2020 r
: Commonwealth of Massachusetts RECEiVEQ
IV- City/Town of AUG 2 4 2020
S stem Pam in Record TOWN OF NORTH ANDOVER
y A g HEALTH DEIpARTMENT
Form 4
DEP has provided this form for use-by local Boards of Health. Other forms may be 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/Right rear of hous�rig side o�hous , Left
Right side of building, Left/Right front of building, Left/Right rear of building, Under
Address
City/Town state Zip Code
2. System Owner:
Name'
Address(if different from location)
city/Town ��G
Telephone Number
B. Pumping record
1. Date of Pumping fiats 2. Quantity Pumped:
Gallons
3. Type-of system: ❑ Cesspooks) tic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes LSO If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
6. System Pumped By:
Nell.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. here contents-were disposed:
G L S: Lowell Waste Water
aA.
Sign a Haul Dabs
t5fbrm4.doc-06/03 System Pumping Record•Page 1 of 1
