HomeMy WebLinkAboutSeptic Pumping Slip - 270 SOUTH BRADFORD STREET 7/2/2018 OnI of �u E
City/Town ofJUL
V SY.4tem Pumping.Record
.
TOM Or NORTH ANDOVER
DEP has provided this ford for use-by local Swards of Health. Other forms may be'used,but the
information,must be substantially the tame as that provided here. Before using.this form,check with your
local Board of Health to determine the forri°t they use.The System Pumping Record must be submitted t®
the local Board of Health or other approving authority.
e cll Infor Mation,
1. System Location: Left/Right front of house, Left/Right rear of house, Left/right side pf house, Left/
Right side of building, Left/Right front of building, Left/Right rear of building, Under deck
Address
,� ^. ✓ ,
cityrrown State Zip Code
2'. System Owner: ,
' Dame'
Address of different from location)
cityfrown Stater Code
` Telephone Number
�.r
B. Ppimpling
�~ . r .
1. Date of PumpingDate 2. Quantity Pumped:
Gallons .��
3. Type-of system: El Cesspools) `tic Tank D Tight Tank
El Other(describe):
4. Effluent Tee Filter present? El Ye. No if yes, was it cleaned? EJ Yes ® No,
5. Condition of Systerq
6: System Pumped By:
Neil.Bateson F5821
Name Vehicle License Number
Bateson Este rises Inc,
Company
7. Loca' �wh contents-were disposed:
L S: Lowell Waste Water
• .
C
F
Sign B Houle cote
t5fbrm4.doc®06/03 System Pumping Record Page 1 of 1