HomeMy WebLinkAboutSeptic Pumping Slip - 322 BOSTON STREET 9/26/2017Commonwealth of Massachusetts
City/Town of.
System Pumping. Record
Form 4
ECEI
) 26 ?017
TOWN OF NORTH ANDOVER
HEALTH DEPARTMENT
DEP has provided this form for use.by local Boards Of Health. Other forme 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 / Right front of house, Left / ghtrear..othous?, Left/ right side of house, Left /
Right side of building, Left / Right front of building, Left / Right rear of building, Under deck
Address
City/Town
2. System Owner:
State Zip Code
Name
Address (if differentfrom location)
City/Town
State , Telephone Number
B. Pumping Record
1. Date of Pumping
3. Type•of system:
Other (describe):
2. Quantity Pumped:
Date Gallons
Cesspool(s) IlkSgiCtic Tank Di Tight Tank
4. Effluent Tee Filter present? No If yes, was it cleaned? E-sEJ Na
5 Condition of sterna
6: System Pumped By:
Neil Bates-or,i
Name
Bateson Enterprises Inc
Company
7. Locatiq!,.ere contents were disposed:
Lowell Waste Water
F5821
Vehicle License Number
3.
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