HomeMy WebLinkAboutSeptic Pumping Slip - 547 WINTER STREET 9/11/2017 Commonwealth of Massachusetts
Cjtj ffown of . RECEIVED
' SyMem Pumping-Record
Form 4 1
TOWN OF NORTH ANDOVM
DEP has provided this form for use-by local Boards of Health. Other forms maybe' TMENT
u 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 farm they use.The System Pumping Record must be submitted to
the local Board of Health or other approving authority.
A. Facility Information r
1
1. System Location: Left I Right frorit of douse, Left I Right rear of house, Left/right side of house, Left
Right side of building, Left/Right front of building, Left/Right rear of building, Under deck
Address
�c u -
ClwTown State - Zip Cone
2. System Owner.
. j
Mame'
1
Address(if different from location)
City/Town ' stat , Zip Cade
Telephone Number
Pumping Record
1. Date of Pumping gate 2. Quantity Pumped: Gallons
3. T e•of s stem: 5.
Type-of system'. ® Cesspool(s) eptic Tank El Tank
® Other(describe):
4. Effluent Tee Filter present? ® Yes o If yes, was it cleaned? Q Yes ❑ No
' S. Condition of System:
6. System Pumped By:
Nell.Batesbn F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Locafi a+i�bp`e contents-were disposed:
GLS: Lowell Waste Water
. F
Sign a Haule Date
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