HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 23 FOREST STREET 10/29/2020 Commonwealth of Massachusetts
City/Town of RECEIVED
System Pumping Record OCT 2 9 2020
Form 4 TGWN OF NORTH ANDOVER
HEALTH DEPARTMENT
DEP has provided this form for use-by local Boards of Health. Other forms maybe 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 n, _ j �-, � fi-L C_'�_
Cityfrown State Zip Code
2. System Owner.
Name' tic)pe
Address(if different from location) u l 1 7 f
Telephone Number
6. 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 ❑ No If yes, was it cleaned? [YYe_z_D No
5. Condition of System:
6. System Pumped By:
Neil.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Locationmbere content§were disposed:
11
G L S. Lowell Waste Water
Sign a Haul Date
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