HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 327 FOREST STREET 9/7/2021 Commonwealth of Massachusetts RECEIVED
City/Town of SEP 0 7 707.1
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
1. System Location: Left/Right front of house, Left/ ht rear of house eft/right side of house, Left/
Right side of building, Left/Right front of building, Led—/Rig rear df building, Under deck
Address '3
city/7own State Zip Code
2. System Owner.
Name'
Address(if different from location)
Telephone Number
B. Pumping Record
1. Date of Pumping Data 2. Quantity Pumped:
3. Type-of system: ❑ Cesspool(s) ptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
6. System Pumped By:
Nell.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Location where contents-were disposed:
G L S Lowell Waste Water
Sign a HbulwU Date
t5forrn4.doa 06/03 system Pumping Record•Page 1 of 1