HomeMy WebLinkAboutSeptic Pumping Slip - 1260 SALEM STREET 8/15/2018 Commonwealth u ft
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City/Town of . RrE.:CEIVED
SOtem Pumping.Record A(JG 15 2018
dForm 4
IMN OF NO[UH ANDOVER,
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®EP has provided this form"for us&by local Boards 'of Health. Other forms may used,but the
information must be substantially the Same as that provided Dere. 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. FactRy. Information1
• t
I. System Location: Left/Right front of house, Left/Right rear of house, Left/right side of house, Left
Right side of building, Left/Right front of building, Left/Right rear of building, Under deck
Address . : Al-
citylrown State Zip Code
2. System Owner �
' blame'
Address(if different from location)
cityllown State r .y tip co
Telephone Number
.B. Pumping Rqcord T7-
1. Gate of Pumping gate 2. Quantity Pumped:
Daltons r�
3. T e"of s
Type-of Y.stern: El
Cesspool(s) epfiic Tank Tight Tank
Other(describe):
4. Effluent Tee Filter present? [] Yes o if yes,was it cleaned? Yes No,
' 5, Condition of System:
6. ,System Pumped By:
Neil.iBatesbn F5821
Name Vehicle License dumber
_Bateson Enterprises Inc-
Company
7. L on hem contents-were disposed:
Lowell Waste Water
' F
Sign a Hbul Crate
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