HomeMy WebLinkAboutSeptic Pumping Slip - 572 FOREST STREET 2/20/2018 jC Commonwealth
System i r' TOWN OF NORM ANDOVER
FQrm 4 HEALTH DEPARTMENT
DEP has provided this form'for use.by local Boards of-Health. Other forms may be'used,but the
'
Information,must be substintialiy the me as that provided here. Before using.this fora,check with your
local Board of Health to determine the forth 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/ i ht front of Nous 1 Left I Right rear of house, Left/right side of house, Left
Right side of building, Left ig t runt of building, Left/Right rear of building, Under deck
Address o �
Gitylrown state Zip Code
2. System Owner.
Address Of different from location)
Ci frown ` Stat c, Zi
're ephane Dumber
i
B. Pumping cor
1. Date of PumpingDate2. Pumped: Daltons ✓ ----`
3. Type-of systeft El cesspool(s) eptic Tank 0 'Tight Tank
Other(describe):
4.. Effluent Tee Filter present.? s ® No if yes, was it cleaned? es Ej No,
' S. Conditio Syst m:
6. System Pumped By:
Neil.Bates7bo F6821
Name Vehicle License Number
Bateson Enterprises Ina
Company
7. Lokwheretents-were disposed:
QLowell Waste Water
Sign date
0brina.docm 06/03 System Pumping Record e Page 1 of 1