HomeMy WebLinkAboutSeptic Pumping Slip - 150 BRADFORD STREET 10/16/2017Commonwealth of Massachusetts
City/Town of
oci ti ?0 17
System Pumping_Record
TOWN OF NORTH ANDMER
Form 4 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 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 1Ight4 of hous_geLeft/ 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
2. System Owner
State
Zip Code
Name*
Address (if different from location)
City/Town
State
.109. Lf
Telephone Number
Zip Code
B. Pumping Record
1. Date of Pumping
(
Date
2. Quantity Pumped:
3. Type systern 0 Cesspooks) eptic Tank 0 Tight Tank
0 Other (describe):
• 4. Effluent Tee Filter present? 0 Yes
5. Condition of System:
Gallons
`1.
ite
If yes, was it cleaned? 0 Yes 0 No,
6: System Pumped By:
Neil, Bateson
Name
Bateson Enterprises Inc
Company
7. Location where contents were disposed:
Lowell Waste Water
F5821
Vehicle License Number
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