HomeMy WebLinkAboutSeptic Pumping Slip - 162 ABBOTT STREET 9/7/2017 Commonwealth of IVlassaohusetts RECEIVED
= W .C4/Town of .
r System Pumping-Record SEI 077 �
Form 4 TOVMOFNORTH ANDOVER
HEALTH DEPARTMENT
DEP has provided this ford for use-by local Boards of-Health. other form's may •used,but the
Information,must be substantially the same as that provided here. Before using.this form., '
heck 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. Faculty. Informi atlon
I. System Location: Left/Right front of House, 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
4At�Yv - c~
Cotrown state zip Code
2. System Owner. .
Name"
Address(if different from location)
City/Town _ S#ate `4b ip Code
l
Telephone Number
i
. . Pumping Rpcord
1. Date of Pumping date 2. Quantity Pumped:
Lallans r
8. Type-of s stem: �l s
Yp system*., ❑ Cesspool(s) ' �-^S Pto'"is Tank ❑ Tight Tank
® Other(describe):
4. Effluent Tee Filter present? ❑ Yes If yes, was it cleaned? ❑ Yes ❑ No,
5. Condition of System:
6: system Pumped By:
Neil.Bateson ` F5821
Name Vehicle License Number
Bateson Ehterprises Inc,
Company
7. Lo where contents-were disposed: r
G L S: Lowell Waste Water
S!qnAqe 4 Haute Date t
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