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HomeMy WebLinkAboutSeptic Pumping Slip - 34 LIBERTY STREET 10/27/2016 Commonwealth of Massachusetts RECEIVED w City/Town of . System Pumping.Record ("� 3 1 Z(h Form 4 fs WN OF NORTH ANDOVER EAt�1`H DEPARTMENT DEP has provided this form far use-.by local Boards of Health. Other forms maybe 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/ ht front. , 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 city/Town State Zip Code 2. System Owner. -� Name' Address(if different from location) cityf own Sta ' de ; - � � , Z� Telephone Number r .B. Pumping !Record . 1. Date of Pumping pate 2. Quantity Pumped: Gallons ���` 3. Type-of system. ❑ Cesspool(s) Q-8 lc Tank © Tight Tank © Other(describe): 4. Effluent Tee f=ilter present? ❑ Yes [ to 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 contents-were disposed: G S: Lowell Waste Water Sign a Haul Date t6form4.doc•06/03 System Pumping Record+page 1 of 1