HomeMy WebLinkAboutSeptic Pumping Slip - 169 BOXFORD STREET 10/16/20171. Date of Pumping
Commonwealth of Massachusetts
CitY/Town of •
System Pumpirig.Record
Form 4
(KI 1 6 7017
TOM OF NORTH ANDOVER
HEALTH DEPAR1MENT
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: Left / , Left/ 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
City/Town
2. System Owner.
State Zip Code
Name`
Address (if different from location)
City/Town '
State Zip Code
Telephone Number
B. Pumping Record
6,t
Date
2. Quattity Pumped:
Gallons
3. Type•of system": 0 Cesspool(s) QpticTank 0 Tight Tank
0 Other (describe):
4. Effluent Tee Filter present? 0 Yes
5. Condition of §)fsterrt:
KJ74-k__
If yes, was it cleaned? ID Yes El No,
6: System Pumped By:
Neil Bateson
' Name
Bateson Enterprises Inc
Company
7. Location where contents were disposed:
GJL. S. Lowell Waste Water
Sign Haul
F5821
Vehicle License Number
Date
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