HomeMy WebLinkAbout- Septic Pumping Slip - 119 LIBERTY STREET 10/31/2018 Commonwealth of Massachusetts UP, cnlyrn ;«
City/Town of
pXWN OF NORTH ANDOVEI,�
f p
bSystem Pumping Record
4
®EP has provided this farm for use-by focal Boards of-Health. Other forms may be'used,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 forrh they use. The System Pumping Record must be submitted to
the local Board of Health or other approving authority.
A. ctliInform' aflon
1. System Location: Left/Right front of douse, Left 16 u e, Left/right side of house, Left f
Right side of building, Left/Right front of buildirig, Left/Right rear of building, Under deck
Address ( t � �.C.
Dityfrown Mete Zip 50 e
2. System t7wrrer:
Name'
Address(if different from location)
cityrrown state• Ll L-Z,ip,Code
elephone Number
Pump in N'
1. Gate of Pumping Date . @u'laity Pumped: Gallons
3. Type-of system. ® Gesspool(s) septic Tank ® Tight Tank
El Other(describe):
4. Effluent Tee Filter present? es ® No if yes, was it cleaned? N®
6. Conditio f System,
6. System Pumped By:
Nell.Bates7on P6821
Name Vehicle License Number
Bateson EhterDrises Ina
Company
7. Lo here contente,were disposed:
4SIgne
Lowell Waste Water
Houle Date
t61brm4.doc-06/03 System Pumping Record d page 1 of 1