HomeMy WebLinkAboutSeptic Pumping Slip - 781 WINTER STREET 10/15/2015 Commonwealth of Massachusetts l �
ity/Town of 1,
SYS
item Pumping-Record XT I
Form 4 IOWN Or NORTH ANDOVER
H LTI�DFAFA T MENT
DEP has provided this form for use-by local 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 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: Lekff( `l ht front of ho , 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
CitylTown State Zip Code
2. System Owner:
Name'
Address(if different from location)
City/Town ' State de ;
Telephone Number +
.B. Pumping Record _ ..
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Type-of system: ❑ Cesspool(s) eptic 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.Bateson ' F5821
Name Vehicle License Number
Bateson Enterprises Ina
Company
7. Lo where contents were disposed:
Q "v44
G L S. W4 Lowell Waste Water
w °�C
jS
Sign a f Haule Date
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