HomeMy WebLinkAboutSeptic Pumping Slip - 178 STONECLEAVE ROAD 11/4/2014 Commonwealth of Massachusefts EN L'
x City/Town
System Pumping Record
a Form 4 vN OF NORTH ANDOVER
H FmI i!r1f�PA ��-'N
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EEP 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 forril they use.The System Pumping Record must be submitted to
the local Board of Health or other approving authority.
A. Fac 111ty, Information
1. System Locatio . Lr /Right front of house, Leff/Righ ear of house; Left/right side of house, Left/
Right side of buil mg, Left i Right front of building, Left/Rig- t rear df building, Under deck
Address r� .. � �"�✓ �.U.�'.�~�
Cityfrown Mete Zip Code
2. System Owner:
Name
Address(if different from location)
Citynown tat C Zi Code
Telephone Number
I
B. Pumping Record
1. Date of Pumping Cete 2. Quantity Pumped: Gallons
. Type of system: Cesspool(s) Septic Tank 0 Tight Tank
Other(describe):
4. Effluent Tee Filter present? ® Yep No If yes, was it cleaned? ® Yes ® No.
5. Condition of S stern: Q
1
6. System Pumped By:
Pfeil Bates®n F5321
Name Vehicle License number
Sateson Enterprises Inc
Company
7. J81ignt' 4HAule ntents were disposed:
Lowell'�/aste Water
_ Date
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