HomeMy WebLinkAboutSeptic Pumping Slip - 475 FOSTER STREET 10/2/2017• Commonwealth of Massachusetts
.City/Town of •
System Pumping. Record
Form 4
OCI 2 ?Oil
• 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
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. Facility Information
1. System Location: Left / Right front of house, ight ref Fiouseieft/ right side of house, Left /
Right side of building, Left / Right front of buil ing, Left / Right rear Of building, Under deck
Address k_( 1 5, •
City/Town
2. System Owner.
State
(‘1--;uN
Zip Code
Name
Address (if differen
from location)
City/Town '
Stater—,. Lc_c r--7 Zip Code
I
Telephone Number
B. Pumping Record
1. Date of Pumping
3. Type -of sytterri:
D Other (describe):
(17
2. Quantity Pumped:
Date
Gallons
Cesspool(s) 9eptic Tank 0 Tight Tank
4. Effluent Tee Filter present? 0 Yes
' 5. Condition of System:
0--6--------
o If yes, was it cleaned? 0 Yes 0 No,
U24),ei, kA.
6: System Pumped By:
Neil. Bateson
' Name
Bateson Enterprises Inc
Company
7. Location where contents were disposed:
aL S Lowell Waste Water
F5821
Vehicle License Number
Sign Haule Date
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