HomeMy WebLinkAboutSeptic Pumping Slip - 43 CANDLESTICK ROAD 7/5/2017Commonwealth of Massachusetts
City/Town ofi •
System Pumping. Record
Forrn 4
C V
JOL0 f 2011
TQW14 OF NORTH ANDOVER
HEALTH DEPARTMENT •
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 forrn, check with your
local Board of Health to determine the form they use. The ystern 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(0/ Rig rrar of hou , Left / right side of house, Left /
Right side of building, Left / Right front of building, Left / Rig
Address
:7_7
City/Town
Z System Owner
State
rear of building, Under deck
Zip Code
Narpe.
Address (if different from location)
City/Town •
State 6,6
Telephone Number
B. Pumping Record
1. Date of Pumping
3. Type -of system*:
0 Other (describe):
Date
Cesspool(s) 1:1-Septic Tank 0 Tight Tank
2. Quantity Pumped:
Gallons
4. Effluent Tee Filter present? 0 Yet 0-1‘3If yes, was it cleaned? 0 Yes 0 No,
Condition of System:
6: System Pumped By:
Neil. Bateson
Name
Bateson Enterprises Inc
Company
7. Location vyire contents were disposed:
Lowell Waste Water
F5821
Vehicle License Number
Signtufe Haul Date
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