HomeMy WebLinkAboutSeptic Pumping Slip - 215 GRANVILLE LANE 1/17/2017Commonwealth of Massachusetts
City/Town of
yste P mpin ecord
Fo 4
IVED
JAN 1 7 ?017
TOWN OF NORTH ANDOVER
HEALTH DEPARTMENT
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
2
1. System Location: Left Cfilit—frontio-f hou_s_e? Left / Right rear of house, Left / right side of house, Left /
Right side of building, Left / Right front of buildirig, Left / Right rear of building, Under deck
Address
City/To n
2. System Owner
ate
Zip Code
Address (if different from lo
City/Town
1. Date of Pumping
3. Type of system:
Other (describe):
4. Effluent Tee Filter present? 10 Yes
A
Cesspool(s)
State
Telephone Number
•
1 7 Quantity Pumped:
[
Septic Tank
Zip Code
0 Tight Tank
' 5. Condition of System:
6: System Pumped By:
Neil Bateson'
• Name
Bateson Enterprises Inc.
Company
If yes, was it cleaned? 0 Yes 0 No,
cvvdLe‘ie
7. Location where contents were disposed:
G Lowell Waste Water
Sign
F5821
Vehicle License Number
Oform4.doc- 06/03 System Pumping Record Page 1 of 1
