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HomeMy WebLinkAboutSeptic Pumping Slip - 128 MILL ROAD 10/16/2017Commonwealth of Massachusetts City/Town of System Pumping Record Form 4 OCT 0 2011 OF NORTH ANDOVER .1[171 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 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: Left / Right front of house, Left / Right rear of hous rghj of house/Left / Right side of building, Left / Rfght front of buildirig, Left / Right rear of building, Underdeck "— Address Vc City/Town 2. System Owner State Zip Code Narrle. Address (if different from location) City/Town ' Code Telephone Number B. Pumping Record 1. Date of Pumping 3. Typeof system': Other (describe): Date 2. Quantity Pumped: Gallons Cesspool(s) LSeptic Tank 0 Tight Tank 4. Effluent Tee Filter present? Ei Yee ' 5. Condition of System: CA. If yes, was it cleaned? Ej Yes C] No, 6: System Pumped By: Neil Bateson • Name Bateson Enterprises Inc Company 7. Loctiqwflere contentsmere disposed: S. Lowell Waste Water F5821 Vehicle License Number gntufe. Haue Date 5form4.doc. 06/03 System Pumping Record • Page 1 of 1