HomeMy WebLinkAboutSeptic Pumping Slip - 1 SCOTT CIRCLE 11/7/2017 Commonwealth of MassachusettsRECEIVEU
w .City/Town of .
pp f
System P'-ump►ift Record 11
r'calrrn 4 froWN OF NORTH ANDOVOI
HEALTH DEPARTMENT
DEP has provided this form for use>by local Boards of Health. Other forms may'be'used,but the
informe0on,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 fo
the local Board of Health or other approving authority.
A. Facility Informlafion
I. System Lacatio • et / fight front of house, Left/Rigl ar cif ouSje eft/right side of house, Left
Right side of bu eft I Right front of buildirig, Left/Right rear cif building, Under deck.
Address
City/rown State Zip Code
2. System Owner: .
' d
Name'
-
Address(if different from location)
cityfrown - $tat Zip Code ;
Telephone Number
t'r
. Pumping fRpcord
? f 77-
1. Date of Pumping bate 2. Quantity Pumped: Gallons
3. Type-of s stem:
yp y• ❑ Cesspoof(s) ptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes 01o If yes,was it cleaned? ❑ Yes ❑ No,
' 5. Condition of tem:
6. System Pumped By:
Nelt Bateson ` F5821
Name Vehicle License Number
Bateson Ehterprises Inc-
Company
. I
?. Location where contents-were disposed:
ALLS-M 2 Lowell Waste water
( . t
. f
Sign a 4 Haule Date
l5form4.doc-06/03 System Pumping Record•Page 1 of 1