HomeMy WebLinkAboutSeptic Pumping Slip - 33 CRICKET LANE 10/30/2017F5821
Vehicle License Number
CEpj
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• t)(1 3 ZOli •
TOWN OF NORTH ANDOVER
HEALTR DLP: AR1 MEN r
DEP has provided this form for use.by local Boards Of Health. Other forms may be usea, DUE me •
information must 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.
Commonwealth of Massachusetts
City/Town of
System Pumping. Record
Form 4
, A. Facility. Information
1. System Location: Left / Right front of house "J-Right rofhojse, Left./ right side of house, Left /
Right side of building, Left / Right front of building, Left / Right rear of building, Under deck
City/Town
2. System Owner:
State
z c(
Zip Code
Nam
Address (if different from location)
City/Town '
State
°Pro
Zi Code
I
i
B. Pumping Record
1. Date of Pumping 2. Quantity Pumped: 1
Date Gallons
3. Typeof system 0 Cesspool(s) ' g--‘-ti-c-Tank 13 Tight Tank
. ',.
13 Other (describe):
4. Effluent Tee Filter present? D Yes o If yes, was it cleaned? 0 Yes E] No,
Telephone Number
Condition of System:
(n,
6: System Pumped By:
Neil. Batesbn •
Name
Bateson Ehterprises Inc
Company
7. Locatio ere ontents were disposed:
Lowell Waste Water
Sign e. H Date
t5forrn4.doc• 06/03 System Pumping Record • Page 1 of 1