HomeMy WebLinkAboutSeptic Pumping Slip - 56 WINDKIST FARM ROAD 9/26/2017 Commonwealth of Massachusetts RECEIVED
CitY/Town of
SIP 2 6,2017
Y, System Pumping.Record
WN OF NORTH ANDOVER
Form HEALTH DEPARTMENT
DE-P has provided this form for use-by 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 1
the local.Board of Health or other approving authority.
A. Facility InforMation
I. System Location: Left/Right front of house, Left/Right rear of house, Left/ bt side of hour Left/ l
Right side of building, Left i Right front of buildirig, Left/Right rear df building, Un er eck
Address
Ike t � r
City/Town State Zip Code
2. System Owner:
Name`
Address(if different from location)
city/Town ` Sta/t/tee Zip
']Code
Telephone Number '"-
-
i
.Be Pumping lk-ecord
1. Date of Pumping 2. Quantity Pumped:
Date Gallons
3. Type-of system: ® Cesspool(s) eptic Tank ❑ Tight Tank
❑ Other(describe):
4.. Effluent Tee Filter present? ❑ Yes o If yes,was it cleaned? ❑ Yes ❑ No.
5. Condition of System:
KA-
6<4s
6. System Pumped By:
Nell.Bates7on F5821
Name Vehicle License Number
Bateson Enterprises Ina
Company
7. Lo tipnrvir e a contents-were disposed:
GLS: Lowell Waste Water
" �7-
SignAture qt HaulerU Date j
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