HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 158 FOREST STREET 8/24/2020 Commonwealth of Massachusetts RECENEo
= City/Town of AUG 2 4 2020
� System Pumping Record TOWN OF NORTH ANDOvER
Form 4 HEALTH DEPARTMENT
r`
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/ i hMight
of house+Left/Right rear of house, Left/right side of house, Left
Right side of building, Left/ ron�of building, Left/Right rear of building, Under deck
Address
City/Town t State Zip Code
2. System Owner.
Name
Day—
Address(if different from location)
CitWTown S Zip Code
- '7 _
Telephone Number
B. Pumping record
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
6. System Pumped By:
Neil.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Loca' . Avh_,em_cgntents-were disposed:
G L S Lowell Waste Water
Sign a Haul Date
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