HomeMy WebLinkAboutSeptic Pumping Slip - 150 SALEM STREET 1/30/2018 RECEIYED
Commonwealth u
CitWTown of
SpMem Pumping. `€ P NORT14 ANDOVER
Form 4 HEALTH DEPARTMENT
CEP has provided this fora for use-by local Boards of Health. Other forms may be bsed,but the
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.
A. Facility. Information,
1. System Location: Left/Eight front of house, Lett/Right rear of house, Left/ i ht side of boos Left/
Right side of building, Left/Right front of buildifig, Left/Right rear of building, n er de'
c
Address
C UJ
City/Town state Zip Code
Z. System Owner:
Name'
Address(if different from location)
Cityfrown ' State �-
A Telephone Number
-13. Pumping Kecord
1. mate of Pumping date 2. Qudntity Pumped:
Gallons ,.
3. Type-of system: Cesspool(s) c Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? Q Yes o If yes, was it cleaned? ❑ Yes ❑ No,
' S. Condition of System: I
6: System Pumped 6y:
Neil.Sates-on F5821
Name Vehicle Llcense Number
Bateson Enterprises Inc,
Company
T. Lo 'o where contentewere disposed:
M S. Lowell Waste Water
UA.
Sign Flaul Cate `
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