HomeMy WebLinkAbout- Septic Pumping Slip - 485 FOSTER STREET 10/19/2018 RECEIVED
N Commonwealth of Massachusetts
0(1 '1
City/Town of ) "
TOWS OF tqORTH ANDOVER
System Pumping Record
Form 4 HEALTH 05)ARVENT
DEP has provided this form for use-by local Boards of Health. Other forms maybe bsed, but the
Information-must be substantially the same as that provided here. 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. Facility information
1. System Location: Left/Right front of housq&Righo—eeof—house Left./right side of house, Left I
Right side of building, Left Right front of bul irig, Left/F;ZU!grht rearfdf building, Under deck
Address A-
awym6mn state .Zip Code
2. System Owner
Name*
Address Of different from location)
cityfrown Stater
Telephone Number
B. Pumping Record
1. Date of Pumping 2. Quantity Pumped:
to Gallons
3. Type-of system: El Cesspool(s) M_s6ptic Tank Tight Tank
[I Other(describe):
4. Effluent Tee Filter present.? E] Yes ZIN� If yes, was it cleaned? Yes No
5. Condition of System- [,e,UZt )I VA,_
6. System Pumped By:
Nell.Bates7bn F5821
Name Vehicle License Number
Bateson �hte rises Inc
Company
7. Location where contents-were disposed:
e MLowell Waste Water
H'iwul Sign Haut Date
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