HomeMy WebLinkAboutSeptic Pumping Slip - 340 BRADFORD STREET 9/12/2017Commonwealth of Massachusetts
City/Town of
System Pumping.Record
Form 4
TOWN OF NORTH ANDO
HEALTH DEPARTMENT
DEP has provided this form for use.by local Boards Of Health. Other forme may be 'used, but the
informationmust 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 ystem 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, Left/ Right rear of house, Left/ rtjage of hotissi? Left /
Right side of budding, Left / Right front of buildirig, Left / Right rear of building, Under deck
Address
City/Town
2. System Owner:
Lefo
State
Zip Code
Address (if different from location)
City/Town
State 3
Zp de
Telephone Number
B. Pumping Record
1. Date of Pumping
3. Type.of system:
0 Other (describe):
Date 2. Quantity Pumped:
Gallons
Cesspool(s) er.--Sfank 0 Tight Tank
4. Effluent Tee Filter present? 0 Yes Erar:r--
' 5. Condition of Syste :
If yes, was it cleaned? 0 Yes Ej No
AjC e--(JeJL
6: System Pumped By:
Neil. Bateson
' Name
Bateson Enterprises Inc
Company
7. Locatio
re contents were disposed:
Lowell Waste Water
/gn HuIe if
F5821
Vehicle License Number
Date
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