HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 205 FOREST STREET 9/25/2020 Commonwealth of Massachusetts
RECEIVED
City/Town of SEP 2 5 ZUU
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 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 house, Left/Right rear of house, Left/right side of house, Left
Right side of building, Left/Right front of building, Left/Right rear of building, Under deck
Address
i
City/Town State Zip Code
2. System Owner.
Name'
Address(i different from location)
CWTown Stat Z e
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped:
Gallons
3. Type-of system: ❑ Cesspool(s) eptic 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:
Neil.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
jSign
wh a contents were disposed:
Lowell Waste Water
Haul Date
t5fbrm4.docr 06/03 System Pumping Record•Page 1 of 1
