HomeMy WebLinkAboutSeptic Pumping Slip - 28 JERAD PLACE 6/29/2017 Commonwealth of Massachusetts RECEIVED
C4/Town of JUL, () t 17
System Pumpin§. ,Record TOWN OF NORTH ANDOVER
Form 4 HEALTH DEPARTMENT
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CEP has provided this form'for use:by local Boards of-Health. Cather 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. F'acfl�ty Information I
1. System Location: Loft I Right front of douse, Left/Right rear of house, Left/right side of house, Left I
Right side of building, Left I Right front of building, Left I Right rear of building, Under deck
Address s
19 fi
f,
Cityrown state Zip Code
2. System Owner:
Name' 1
• f
I
Address(if different from location)
Citylrown ` State- Zip Code
Telephone Number •'—;,
. Pumping itecord �.
' r
1. Cate of Pumping - 2 uantity Pumped:
Date Gallons ,.
3. Type-of system: ❑ Cesspool(s) Septic Tank Tight Tank =.
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? Yes ❑ No,
5. Condition of System:
C C',
6. System Pumped By:
Neil.Bateson • F5821
Mame Vehicle License Number
Bateson Enterprises Inc
Company
7. Lo on-wh re contents-were disposed:
GLS: Lowell Waste Water
Sign a Haule Date
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