HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 327 FOREST STREET 10/29/2020 : Commonwealth of Massachusetts
= City/Town of MTECEIVED
System Pumping Record c: if 2q 2020
�. Form 4 TC'NN OF NORTH A�NDOVER
DEP has provided this form for use=by local Boards of Health. Other forms may use bRutNe
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
CiWrown State Zip Code
2. System Owner:
Name
Address(if different from location)
CitylTown State C — Ics
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 If yes, was it cleaned? ❑ Yes ❑ No
5. Condi' of System: `�/9
e '
6. System Pumped By: S
Neil.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc-
Company
7. Loeaiti9n where contents were disposed:
G L S: Lowell Waste Water
A.
Sign a Haul Date
t5form4.doc•06/03 System Pumping Record•Page 1 of 1