HomeMy WebLinkAboutSeptic Pumping Slip - 268 REA STREET 9/26/2017Commonwealth of Massachusetts
City/Town of. •
System Pumping_Record
Form 4
V
SE.P 26 701 7
TOWN OF NORTH ANDOVER
HEALTH DEPARTMENT
DEP has provided this form` for use by local Boards of Health. Other forms may be 'used, but the
informationmust 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. Facility Information
1. System Location: Left / Right front of house, Left jq rear of hou_s , Left / right side of house, Left /
Right side of building, Left / Right front of building, Left / Right rear of building, Under deck
Zip Code
2. System Owner:
Name.
Address (if different from location)
City/Town '
State
tz;
ip C de
Telephone Number
B. Pumping Record
1. Date of Pumping
Date
3. Typeof system: 0 Cesspool(s)
13 Other (describe):
4. Effluent Tee Filter present?
2. Quantity Pumped:
Eter---atic Tank Li Tight Tank
5 Condition of Systertr
6. System Pumped By:
Neil Batesbn
Name
Bateson Enterprises Inc
Company
7. LocalLocaahrcontentswere disposed:
Lowell Waste Water
Sign
If yes, was it cleaned? [5-17I: No,
LQ
F5821
Vehicle License Number
Date
c(
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