HomeMy WebLinkAboutSeptic Pumping Slip - 115 OLYMPIC LANE 10/25/2017 .4 Commonwealth of Massachusetts OtECEIVED
u CitY/Town of . �� m�
System Pumping-Record
Form 4 TOWN OF NORTH ANDOVER
HEALTH DEPARTMENT
DEP has provided this form for use-by focal Boards of Health. Other forms may'be'used, but the
information,must be substantially the same as that provided here. Before using.this form, '
heck 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. Facfl�ty Informs ation I
1. System Lacatio Le gh ortt house Left/Righ#rear of house, Left/right side of house, Left/
Right side of bu► ing, Left/Rig o uildirig, Left/Right rear of building, Under deck
Address
City/Town State Zip Code
2. System Owner:
Name
Address(if different from location)
City/rown ' State Ip Code
Te1ep one Number
b
' f
. Pumping Record
1. bate of Pumping Dat -� 2. Quantity Pumped:
Gallons
3. Type-of system: ® Cesspool(s) is Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ® Yes a<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. Locafin,aNyhere contents-were disposed:
JG-
LS-P Lowell Waste Water
a Ha ule Date
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