HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 242 FOSTER STREET 10/29/2020 Commonwealth of Massachusetts
City/Town of RECEIVED
System Pumping Record OCT 2 9 2020
Form 4 TOWN OF NORTH ANDOVER
s�• HEALTH DEPARTMENT
DEP has provided this form for use:by local Boards of Health. Other forms maybeused,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, Le g rear of building, Under deck
-- ,
Address ;
Cityrrown State Zip Code
2. System Owner.
Name
Address(if different from location)
Citylrown State Zio de
' c 17'G
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 Syste
6. System Pumped By:
Neil.Bates-on F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Location where contents were disposed:
ISigne
Lowell Waste Water
Z:E
Haul Date
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