HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 895 FOREST STREET 3/10/2021 : Commonwealth of Massachusetts RECEIVED
City/Town of MAR 10 2021
NORTH
System Pumping Record TOH�T{DEPARTMENT ANDOVER
Form 4
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
1. System Location: Left/Right front of house, Left/Right rear of house, Left/ ht side;qfhous LeftRight side of building, Left/Right front of building, Left/Right rear of building, n er
Address L
City/Town O�t State Zip Code
2. System Owner.
Name'
Address(d different from location)
CityfTown State Tip Code
C Fs-S�oF�
Telephone Number
B. Pumping Record
1. Date of Pumping Cate 2. Quantity Pumped:
Gallons
3. Type of system: ❑ Cesspool(s) eptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:' tj�� raja lti Jc
6. System Pumped By:
Neil.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Lo ' w e contents-were disposed:
L S Lowell Waste Water
a- a� -&7
Sign aobuletuDate
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