HomeMy WebLinkAboutSeptic Pumping Slip - 7 INGALLS STREET 10/16/2017" 5. Condition of §yste :
Commonwealth of Massachusetts
City/Town at
System Pumping. Record
Form 4
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•
,EIV
orl "I Li 2017
OWN OF NORTH ANDOVER
EALTI-1 DEPART ENT
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, Left / Right rear of hous Jright iajouse Left /
Right side of building, Left / Right front of buildirig, Left / Right rear Of building, Under deck
Address
1-7
City/Town
2. System Owner:
State Zip Code
Narpe•
Address (if different from tom ion)
City/Town •
•
State.
de
Telephone Number
B. Pumping Record
1. Date of Pumping
3. Type•of system':
El Other (describe):
t c9 —
Date
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2. Quantity Pumped:
tic
Gallons
Cesspool(s) D-Besplink El Tight Tank
4. Effluent Tee Filter present? El Ye s Erl (Tr.-- If yes was it cleaned/ TT D Yes Ej No,
GAS-
6: System Pumped By:
Neil. Bates -on
' Name
Bateson Enterprises Inc
Company
7. Locatio kere contents -were disposed:
Lowell Waste Water
F5821
Vehicle License Number
t5form4.doc- 06/03 System Pumping Record • Page 1 of 1