HomeMy WebLinkAboutSeptic Pumping Slip - 41 NORTH CROSS ROAD 11/11/2016 Commonwealth of Massachusetts
RECEIVED
City/Town of NOV I f Z01
° System Pumping-Record TOWN OF NORTH ANDOVER
IARTMFMT
Form 4
J'
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,, a /Rig rear o� , Left/right side of house, Left/
Right side of building, Left/Right front of b ildi g, Left/Right rear of building, Under deck
Address
Y
C _
Cit /town S tate -
Zip Code
2. System Owner,
V, A (A
Name'
Address(if different from location)
citylrown ' Stat
Telephone Number i
.B. Pumping Kecord
1. date of Pumping Date 2. Quanti Pumped:
Gallons
3. Type-of system. ❑ Cesspool(s) a tle Tank ;
p ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes ( a If yes, was it cleaned? ❑ Yes ❑ No,
' 6. Condition of System:
6: System Pumped By:
Neil.Batesan - F6821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Lo tion- ere contents were disposed:
G S'.D Lowell Waste Water
Sign e Haul Date
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