HomeMy WebLinkAboutSeptic Pumping Slip - 222 BRIDGES LANE 10/25/2017 Commonwealth of Massachusetts RECEIVED
CiWTown of
stern Pumping--Record �a� 2 ,0011
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TOWN CSE NORTH ANDOVER
Form 4HEALTH DEPARTMENT
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DEP has provided this farm,for use-by local Boards of Health. Other form's may•be'used, 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 forrh they use. The System Pumping Record must be submitted to
the local.Board of Health or other approving authority.
A. Pactlity. Information l
I. System Location: Le front of lio , Left I Right rear of house, Left/right side of pause, Left/
Right side of building, Left/Rig ront of buiidirig, Left/Right rear of building, Under deck
Address
w /
tom- e �
city/Town state Zip Code
2. System Owner.
Name'
Address(if different from location)
City/rown State- (y ZID Code
Telephone Number
r
. Pumping Record �
9. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Type-of s
Yp Y.stem:
® Cesspool(s) eptic Tank. ❑ Tight Tank
® Other(describe).
i
4. Effluent Tee Filter present? ❑ Yes o If yes,was it cleaned? ® Yes ❑ No,
5. Condition of System. 1
NIL))14-
6.- System Pumped By.-
Nell.
y:Nell.Bateson F5821
Name Vehicle license Number
_Bateson Enterprises Ina l
company
i
7. Locati here contents-were disposed:
G. ' Lowell Waste Water
- UA
f
Sign a Haute Date E
Sforrn4.dow 06/03 System Pumping Record•Page 9 of 1