HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 75 FOSTER STREET 10/7/2020 Commonwealth of Massachusetts RECEIVEDOCT 0 7 2020
_ City/Town of
TOWN OF NORTH ANDOVER
System Pumping Record HEALTH DEPARTMENT
Form 4
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 ht front of hous(o, Left/Right rear of house, Left/right side of house, Left 1
Right side of building, Left/Right ron o uildirig, Left/Right rear of building, Under deck
Address
Citylrown State Zip Code
2. System Owner.
Name
Address(if different from location)
Citylrown state 6c Zip Code
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 a_1�0 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' contents-were disposed:
G L S: Lowell Waste Water
qS�ign Date
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