HomeMy WebLinkAboutSeptic Pumping Slip - 280 CANDLESTICK ROAD 9/12/2017Commonwealth of Massachusetts
City/Town of.
System Pumping. Record
Form 4
TOWN OF NORTH ANDOVER
HEALTH DEPARTMENT
DEP has provided this form. for useby local Boards of 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 form they use. The System Pumping Record must be submitted to
the local Board of Health or other approving authority.
A. Facility Information
, •
1. System Location: Left Liit front of houst eft / 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
,e) s
City/Town
2. System Owner.
Name.
State
Zip Code
Address (if different from location)
City/Town
St
Zip ciria
Telephone Number
•B. Pumping Record
1. Date of Pumping
3. Type -of system':
Other (describe):
Date
Cesspool(s)
2. QuanW Pumped:
Gallons
ptic Tank El Tight Tank
4. Effluent Tee Filter present? El Yes
Condition of System:
0-C
If yes, was it cleaned? 0 Yes 0 No,
A ÷tkue-ac__
System Pumped By:
Neit Bates -on
Name
Bateson Enterprises Inc
Company
7. Loationwhere contents were disposed:
Lowell Waste Water
F5821
Vehicle License Number
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