HomeMy WebLinkAboutSeptic Pumping Slip - 127 VEST WAY 10/25/2017 Commonwealth of Massachusetts RECEIVED
CitV/Town of . -2 5 OM
701,.E
ystelm Pumping.Record
oy C O NORTH ANDOVER
F
H AUH DEPARTMENT
DEP has provided this farm far use-by local Boards of Health. Other form's maybe`used, but the
information,must be substantially the tame as that provided here. Before using.this form,check with your t
local Board of Health to determine the form they use.The System Pumping Record must be submitted tr)
the local Board of Health or other approving authority.
A. Facility. Informlation
p f
1. System Location: Left/Right front of house• /Ri rear of ho eft/right side of house, Left
Right side of building, Left/Right front of building, Left/Rig rear of building, Under deck
Address
City/Town State Zip Code
2. System Owner:
Name'
Address(if different from location)
Citylrown Stat C 1Zip Code
L`1
Telephone Number
.B. Pumping k-ecor
1, Date of Pumping nate Quantity Pumped:
Cellons r `
3. Type-of system* ® Cesspool(s) tio`Tank Tight Tank
® Other(describe):
4. Effluent Tee Filter present? ® Yes o If yes, was it cleaned? E Yes ® No,
5. Condition of stem:
6. System Pumped By:
Neil.Bateson - F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
i
7. Location where contents were disposed:
Ls. Lowell Waste Water
10A B
SignAqe cf HaulWU
Date
5form4.doc-06/03 System Pumping Record•Page 1 of 1