HomeMy WebLinkAbout- Septic Pumping Slip - 209 BRIDGES LANE 10/19/2018 RECEIVED
Commonwealth of Massachusefts
City[rown of '19 2018
System Pumpling Record
TOWN OF NORTH ANDOVER
Fonn 4 HEALTH DEPARTMENT
CEP has provided this form for use-by local Boards of Health. Other forms maybe'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 forrh they use, The;3ystem Pumping Record must be submitted to
the local Board of Health or other approving authority.
Facility Information
System Location: Left/Right front of house, Left Y/RIg ight rear, �q Left/right side of house, Left I
Ic
Right side of building, Left Right front of building, e rear of building, Under deck
�A,dddare,�ss .
city/rown State Zip Code
2. System Owner
Name
Address of different from location)
cityiTown stater Zip Code
Telephone Number
.13. Pumping Record 6 6
1. Date of Pumping Quantity Pumped:
ns 15
Date Gallo
3. Type-of system*. El Cesspool(s) septic Tank Tight Tank
Other(describe): --2(17
4. Effluent Tee Filter present? Y Yes E3 No If yes, was it cleaned? O/Yes No
6, Condition of System:
Led
6. System Pumped By:
Neil.Meson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Loc atl!
, _here contents-were disposed:
G,L a. Lowell Waste Water
Sign e 116ula Date
t5fbrm4.doo-06/03 System Pumping Record Page 1 of 1