HomeMy WebLinkAboutSeptic Pumping Slip - 1014 TURNPIKE STREET 6/16/2017F5821
Vehicle License Number
Cornmonwealth of Massachusetts
City/Town of
System Pumping. Record
Form 4
ECENED
0 5 ZU11
TOWN OF NORTH ANDOVER
LIN DEPARTMENT
HEA
DEP has provided this form' for use.by local Boards & 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 foul, they use. The System Pumping Record must be submitted to
the local Board of Health or other approving authority.
, A. Facility Information
1. System Locatio ircji Righartihr?;oihou eft / Right rear of house, Left/ right side of house, Left /
Right side of buil ing, Left / Rig uildirig, Left / Right rear of building, Under deck
Address
1 )L{AC 14yD ' k
City/Town
2. System Owner
Narpe.
Akr 5
JJ,
State
dog
Zip Code
Address (if different location)
City/Town
fr
State Zip Code
Telephone N umber
B. Pumping Record
1. Date of Pumping ( 2 uantity Pumped:
Date Gallons
3. Type.of system 0 Cesspool(s) - Septic Tank 0 Tight Tank
Other (describe):
4. Effluent Tee Filter present? 0 Yes No
5. Condition of System:
6. System Pumped By:
Neil Bateson -
Name
Bateson Enterprises Inc
Company
7. Loca re contents were disposed:
If yes, was it cleaned? 0 Yes 0 No,
J1)0coAct[ e(
Lowell Waste Water
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