HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 327 FOREST STREET 1/14/2021 ._ Commonwealth of Massachusetts RECEIVED
City/Town of JAN 14 2021
System Pumping Record Tov,,N OF NORTH ANDOVER
Form 4 hE;\LfH DEPARTMENT
DEP has provided this form for use-by local Boards of Health. Other forms may 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 ' h rear of ho . , Left/right side of house, Left
Right side of building, Left/Right front of building, Left/Right rear of building, Under deck
Address -7 4` � —
City/Town 1 State Zip Code
2. System Owner.
Name'
Address(ir different from location)
citjNTown
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 ailo 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. %lHitbiul
tents-were disposed:
Lowell Waste Water
Sig Data
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