HomeMy WebLinkAboutSeptic Pumping Slip - 3 BRECKENRIDGE ROAD 2/20/2018 Commonwe [ f Massachusefts RECEIVED
UWTown of
FEB A0 2016
oSy.4tem Pumplln§, rd
TOWN OF NORT14 ANDOVER
4Form 4 HEALTH DEPARTMENT
DEP hay's provided this form*for use-by local Boards o*f-Health. Other forms may be'used,but the
Information,must be substantially the same as that provided here. Before using.this forme,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. fl I fl n
1. ,System Locatio ,,'C��ight oft�f Yiou�e i�/Fight rear of house, Left/right side of house, Left/
Right side of bui`Idlhg, Left/Flight froo uildirig, Left/Right rear of building, Under deck
Address
Cityltown State Zip Code
2: System Owner.
blame'
Address(if different from location)
Citylrown State- Zip Codp
"telephone Number
• i
® Pumpingicr
9, fate of Pumping Date 2. Quantity Pumped: Gallons
3. Type-of system: Cesspool(s) [1-86066" 0 Tight"Tarek
® ether(describe):
4. Effluent Tee Filter present? El Yes 0-..N' .r......
If yes, was it cleaned? Ej Yes ❑ No,
5. Condition f stem:
6: System Pumped By:
Neil.Sates-on ' F5821
Name Vehicle License Number
Bateson Enterprises Ina
Company
7, Locatiap Where contents-were disposed:
S: Lowell Waste Water
•
Sign hlUle Cate
t8fbanCdood 06103 System Pumping Record d page 1 of 1