HomeMy WebLinkAboutSeptic Pumping Slip - 42 FOSTER STREET 10/16/2017Cornmonwealth of Massachusetts
City/Town of
System Pumping. Record
Form 4
EC V
TOWN OF NORTH ANDOVER
HEALTH DEPARTMENT
DEP has provided this form. for useliy 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
!coal 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
•
I. System Location: Left / Right front of house, Left/ Right rear of house, Left /i litside of hous Left /
Right side of building, Left / Right frOnt of building, Left / Right rear cif building, Un
Address
City/Town
2. System Owner:
rt
State •Zip Code
Name'
Address (if different from location)
City/Town
B. Pumping Record
1. Date of Pumping
Date
Stat
Telephone Number
Zip Code
(-(-7
2. Quantity Pumped:
Gallons
3. Type -of system 0 Cesspool(s) ic Tank ID Tight Tank
Other (describe):
4. Effluent Tee Filter present? P Yes 11-446
5 Condition of System:
6: System Pumped By:
Neil Bates -on •
' Name
Bateson Enterprises Inc
Company
7. 10 contents -were disposed:
Lowell Waste Water
If yes, was it cleaned? 0 Yes 0 No,
F5821
Vehicle License Number
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