HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 770 FOREST STREET 11/30/2020 Commonwealth of Massachusetts RECEIVED
City/Town of NOV 3 0 2020
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 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
ft,,a Rightront of house. Left/Right rear of house, Left/right side of house, Left
1. System Location: L�e
Right side of building, Left/ RiW ron of building, Left/Right rear of building, Under deck
Address
7?
Cityrrown State Zip Code
2. System Owner n
Name I
Address(if different from location)
CiWown State �p e
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2• Quantity Pumped: Galions
3. Type of system: ❑ Cesspool(s) eptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System: i
'A - �
6. System Pumped By:
Neil.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Locatjon-whi�re contents were disposed:
aS. Lowell Waste WaterSignul Date
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