HomeMy WebLinkAboutSeptic Pumping Slip - 84 SUGARCANE LANE 9/26/2017 Commonwealth of MassachusettsRECEIVED
W City/�"own of .
t
System IPumping,Recordl ."�:�
F®rm 4 TOWN OF NORTH ANDOVER
• HEALTH DEPARTMENT
DEP has provided this form for useaby 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/9 r nt of Nous Left/Right rear of house, Left/right side of house, Left/
Right side of building, Left/Rigl t f on o building, deft/Right rear of building, Under deck
Address
'c..� SA
Citylrown State Zip Code
2; System owner:
Name'
Address(if different from location)
City/Town state- Zip Code
Telephone Number
B. Pumping Rpcor
9. Gate of Pumping 2. Quantity Pumped: --=•-r
. Gate Gallons
3. Type-of system: ❑ Cesspool(s) [9 Septic Tank ❑ Tight Tank
❑ other(describe):
4. Effluent Tee Filter present? ® Yes 13,No If yes, was it cleaned? ❑ Yes ❑ No,
5. Condition of System:
6. System Pumped By:
Neil.Bateson - F5821
Name Vehicle License Number
Bateson Enterprises Inc-
Company
7. Locatin.,. here contents were disposed:
GL .. Lowell Waste Water
Sign a Haule Date
System Pumping Record•page 1 of 1