HomeMy WebLinkAboutSeptic Pumping Slip - 66 CEDAR LANE 10/25/2017 Commonwealth of Massachusetts
M. M
CRY/Town of RECEIVED
System Pumping.Record LII ;.. 5 701
Form 4
TOWN OF NORTH ANDOVER
DEP has provided this form for use-by local Boards 6f Health. Other forms may, l�`t H , bu he
p y y use , 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 fon"n they use. The System Pumping Record must be submitted;to
the local Board of Health or other approving authority.
A. Facflity. InforMation
1. System Location: Left/Right front of House, Left/Right rear of housUL� / rid of house,LeftRight side of building, Left/Right front of building, Left/Right rear ong, Under dec
Address
City/rown State Zip Code
Z. System Owner:
Name'
Address(if different from location)
Civrown ' State i Code
Telephone Number "
. Pu�vrping JRgcord �
• 7
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1. Date of Pumping Date 2. Quantity Pumped:
Gallons `
3. Type-of system: ❑ Cesspool(s) eptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yep o If yes, was it cleaned? ❑ Yes ❑ No,
5. Condition of System: /
6. System Pumped By:
Neil.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Loca' p here contents-were disposed:
G L Lowell Waste Water
i
SignAt4e I Haute Date
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