HomeMy WebLinkAboutSeptic Pumping Slip - 209 BRIDGES LANE 9/26/2017Commonwealth of Massachusetts
City/Town of
System Pumping. Record
Form 4
*ciV
SEP 2 6 7011
TOWN OF NORTH ANDOVER
'HEALTH DEPARTMENT •
DEP has provided this formfor 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
the local Board of Health or other approving authority.
. A. Facility Inforthatiop
1. System Location: Left / Right frobt of house, Left / igitJr of hogs. , Left / right side of house, Left /
Right side of building, Left / Right frOnt of buildirig, Left / RightFear cif building, Under deck
Address
f•SC)
City/Town
2. System Owner
f
1kl--(4--("L-,
Zip Code
State
Name
Address (if different from location)
City/Town '
State
Zi
Telephone Number
B. Pumping Record
1. Date of Pumping
3. Type.of sytterri:
'7
2. Quantity Pumped:
Date
El Cesspool(s)
Ej Other (describe):
4. Effluent Tee Filter present?
' 5. Condition of System:
6: System Pumped By:
Neil Batesbn
Name
Bateson Enterprises Inc
Company
Gallons
eptic Tank D Tight Tank
7. Location here contents were disposed:
Signtufe q Haule
N
Lowell Waste Water
If yes, was it cleaned?
F5821
s No
Vehicle License Number
Date
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