HomeMy WebLinkAboutSeptic Pumping Slip - 258 BRIDGES LANE 10/30/2017E1VE
Commonwealth of Massachusetts
City/Town of . rc] (in mil
System Pumping. Record
Form 4
DEP has provided this form for uset)y 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 faun 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 house, Left 1Rihr of hoqse, Left/ right sislaof. Jouse, Left /
Right side of building, Left / Right front of building, Left Tight rear of building nder dec
City/Town
2. System Owner:
State
Zip Code
Narrze
Address (if different from location)
City/Town '
State
Telephone Number
Zip Code
-7' —
B. Pumping Record
1. Date of Pumping
Date
2. Quantity Pumped:
3. Type•of system': Ej Cesspool(s) —SiPtic Tank El Tight Tank
TOWN OF NORTH ANDOVER
HEALTH DEPARTMENT
Other (describe):
4. Effluent Tee Filter present?
' 5. Condition of System:
Gallons
System P mped By:
Neil. Batesbn
' Name
Batepon Enterprises Inc
Company
No If yes, was it cleaned? [3--YesD Na
c)(
1/ 110 4"'VkAr
ere contents were disposed:
Lowell Waste Water
Signt4e q Haul
F5821
Vehicle License Number
Date
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