HomeMy WebLinkAboutSeptic Pumping Slip - 439 WINTER STREET 10/30/2017Commonwealth of Massachusetts
City/Town of. -
System Pumping. Record
Form 4
E
1
OC, 0 1 -
TOWN OF NORTH ANDOVER
HEALTH DEPARTMENT
DEP has provided this form for usaby local Boards of Health. Other forms may be used, but the
informationmust be substantially the same as that provided here. Before using.this form, check 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. Facility Information
1. System Location: Left / Right front of hous e f houseAeft/ right side of house, Left /
Right side of building, Left / Right front of b "fdthg, Left / Right rear of building, Under deck
2. System Owner:
Narrie.
Address (if different from location)
City/Town '
State AIL c L.) Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping 2. Quantity Pumped:
Date Gallons j
• \
3. Typaof system 0 Cesspool(s) L eptic Tank ID Tight Tank
E3 Other (describe):
4. Effluent Tee Filter present? El Yes
5. Condition of System:
cAs
If yes, was it cleaned? 0 Yes Ej No,
6: System Pumped By:
Neil. Bateson •
` Name
Bateson Enterprises Inc
Company
•
7. Loca *o here contents were disposed:
Lowell Waste Water
F5821
Vehicle License Number
Sign e qt Hauler( Date
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