HomeMy WebLinkAboutSeptic Pumping Slip - 485 FOREST STREET 3/10/2017{To
Commonwealth of Massachusetts
City/Town of
ystem Pu pin &cord
For 4
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 Infor ation
1. System Location: Left / Right front of housq( / Right6ffil , eft/ right side of house, Left /
Right side of building, Left / Right front of bail mg, Left / RighTrear of building, Under deck
2. System Owner:
Name'
Address (if differentdfffeent frornlocation)
City/Town
St t
Zip Code
Telephone Number
Pu
pans pc r
1. 1 '17
Date of Pumping
Date
3. Typeof system 0 Cesspool(s) [Sank
0 Other (describe):
4. Effluent Tee Filter present? 0 Yea
5 Condition of System: i
lk_it)rfvva
I
2. Quantity Pumped:
. REC.,EIVE,D
TOWN OF NORTH ANDOVER,
HEALTH DE.PARTMENT
1
Gallons
0 Tight Tank
If yes, was it cleaned? EJ Yes Ej No,
t-ecvrt itA
6: System Pumped By:
NellBateson
• Name
Bateson Enterprises Inc
Company
7. Locjopwter c ntents were disposed:
G.1. S. Lowell Waste Wa
Sign e Haul
F5821
Vehicle License Number
Date
t5form4.doc. 06/03 System Pumping Record a Page 1 of 1