HomeMy WebLinkAboutSeptic Pumping Slip - 103 BRADFORD STREET 6/21/2017Commonwealth of Massachusetts
City/Town of.
System Pumping. Record
Form 4
. RECEIVED
• J!„J •U13. Ui
TOWN OF NORTH ANDOVER
DEP has provided this form' for use by local Boards of Health. Other for qv= • 'zit'diigt.it 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 Inforthation.
1. System Location: Left / Right front of house, Left/ Right rear of hous
Right side of building, Left / Right front of buildirig, Left / Right rear Of
Address
City/Town
2. System Owner:
Name'
6:7 •f.rexc
State
[de of house eft /
Zip Code
Address (if different from location)
City/Town ' State
Zip de
Telephone Number
•B. Pumping Record
1 Date of Pumping
Date 2. yantity Pumped: Gallons
3. Type -of system': 0 Cesspool(s) El t;ptic Tank D Tight Tank
Ei Other (describe):
4. Effluent Tee Filter present? 0 Yes
5. Condition of pystem:
if yes, was it cleaned? Yes No,
7,fir,A4dt.A if2V '(A‘
6: System Pumped By:
Bateson •
• Name
Bateson Enterprises Inc
Company
7. Locati9flwere contents- were disposed:
Lowell Waste Water
F5821
Vehicle License Number
Sigritufe. HauJe W Date
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