HomeMy WebLinkAboutSeptic Pumping Slip - 161 BRIDGES LANE 10/25/2017 RKEIVED
. Commonwealth of Massachusetts
M C4/Town of OC"T 25
Syat+em Pumping.Record TOWN OF NORTH ANDOVER
Form 4 HEALTH DEPARTMENT
1
DEP has provided this form*for use-by local Boards of-Health. Other forms may `used, but the -
infortnatlon•must be substantially the same as that provided here. Before using.this form,check with your
local Board of Health to determine the forri°r they use.The System Pumping Record must be submitted to
the local Board of Health or other approving authority.
A. Facility Inform' ation
1. System Location: Left/Right front of hous Le'bh6p �ar_ Left/right side of house, Left
0 Right side of building, Left/Right front of building, Left/Right rear of building, finder deck
• i
Address / ,• / p
t
Citylrown State Zip Code
2. System Owner:
WCA =
Name'
Address(if different from location)
Cityfrown ` State Zip Code
Telephone Number
. Pumping it cor ,
1. Gate of Pumping gate 2• Quantity Pumped:
Gallons
3. Type-of system: ❑ Cesspool(s) EPXVfRcTank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Y" 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. Location where contents.were disposed:
L S Lowell Waste Water
F
Sign a qt Hauls,() Date
t5form4.doc•08/43 System Pumping Record•Page 1 of 1
r