HomeMy WebLinkAboutSeptic Pumping Slip - 50 SAW MILL ROAD 6/7/2017Cornmonwealth of Massachusetts
City/Town of
System Pumping. Record
Form 4
JUNI 3 7, i (
TOWN OF NOR I H 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
1. System Location: Left / Right front of house, 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
City/Town State •Zip Code
Z. System Owner
Narrm.
Address (If different from location)
City/Town
State
Telephone Number
B. Pumping Record
1. Date of Pumping
Date
2. Quantity Pumped:
Gallons
3. Typebf system : Cesspool(s) eptic Tank El Tight Tank
Other (describe):
4. Effluent Tee Filter present? 0 Yee If yes, was it cleaned? D Yes E] No
" 5. Condition of stem:
. jiLbr
6: System Pumped By:
Nell Bateson
' Name
Bateson Enterprises Inc
Company
7. Locati. where contents were disposed:
at. s.
F5821
Vehicle License Number
Sign e. Haul Date
5form4.doc• 06/03 System Pumping Record • Page 1 of 1