HomeMy WebLinkAboutSeptic Pumping Slip - 73 FOREST STREET 9/26/2017 Commonwealth of Massachusetts
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System Pumping.Record SIA1 2 62017
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TOWN OF NORTH ANDOVER
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DEP has provided this form for use-by local Boards of Health. Other forms maybe•used,Du[Ke
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. r
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A. Facliit / InforMation .
1. System Location a tigh ortili of house aft/Right rear of house, Left/right side of house, Left
Right side of builLeft/Ri ht front of building, .eft/Right rear of building, Under deck
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Address --
4_ c cam _
City/Town State Zip Code
2'. System Owner.
Name'
•
Address(if different from location)
City/Town ' State r--.. Zip Code ••
Telephone Number
.13. Pumping Raword
9. Date of Pumping 2. Quantity Pumped: --=-
• Date _.�-� Gallons
3. Type-of system: ® Cesspool(s) a pts is Tank Tight Tank
® Other(describe): 1
4. Effluent Tee Filter present? ® Yes E],N If yes, was it cleaned? [—I Yes 0 No,
i
' S. Condition of System
6. System Pumped By:
Nell.Bateson F5821
Name Vehicle license Number
Bateson Enterprises Inc-
Company
7. Locatio..�M�ere contents-were disposed:
dLSQ Lowen Waste Water
IWA.
S1gnAWe Haule Date
0orm4.doca 08103 System Pumping Record•page 1 of 1