HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 333 FOREST STREET 9/7/2021 RECEIVED
: Commonwealth of Massachusetts
City/Town of SEP 0 7 2021
System Plumping Record TCWN OF NORTH ANDOVER
HEALTH DEPARTMENT
Form 4
DEP has provided this form for us&by local Boards of Health. Other forms may be*used,but the
information,must be substantially the two 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 ' t front of do , Left/Right rear of house, Left/right side of house, Left,/
Right side of building, Left/Right front of building, Left/Right rear of building, Under deck
Address C'^� l "\
Cityrrown State Zip Code
2. System Owner.
Name'
Address(if different from location)
CitylTown state� a ^�1 Zip�Gl e
Telephone Number `� 1
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 Jo 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. Location Wb_ere contents-were disposed:
_L S` Lowell Waste Water
�' -
SignAWe cfHaulwU Data
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