HomeMy WebLinkAboutSeptic Pumping Slip - 116 BRIDGES LANE 9/26/2017Commonwealth of Massachusetts
City/Town of
System PumpingRecord
Form 4
SF P 261.011
TOO OF NORTH ANDOVER
HEALTH DEPARTMENT
DEP 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 forrn, 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. Factqty. Information
1. System Location: Left kftiglit1r;;;-1tof hou , Left / Right rear of house, 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
C (8f
2. System Owner.
State
Zip Code
Name
Address (if different from location)
City/Town •
`1.
Stat
de
Telephone Number
B. Pumping Record
1. Date of Pumping
3. Type.of system':
El Other (describe):
itr
Cesspool(s)
2. Quantity Pumped:
Gallons
eptic Tank 0 Tight Tank
4. Effluent Tee Filter present? 0 Yep 0-4 cirr--- If yes, was it cleaned? El Yes 0 NO,
" 5. Condition of System:
tVe7c(1.1/4-0,i(
6: System Pumped By:
Neil. Bateson •
' Name
Bateson Enterprises Inc.
Company
7. Lo
re contents were disposed:
Lowell Waste Water
Sign Haul
F5821
Vehicle License Number
Date
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