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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( t5forrn4.doc 06/03 System Pumping Record • Page 1 of 1