HomeMy WebLinkAboutSeptic Pumping Slip - 31 VEST WAY 6/5/2017Commonwealth of Massachusetts
City/Town of
yst- Pu pnec rd
Fo 4
,R1N. 2,09
TOWN OF NORTH ANDOVER
HEALTH DEPARTMENT
DEP has provided this form for usetly 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 1 for atlop
Right side of building, Left / Right front of buCing,
1. System Location: Left / Right front of house
2. System Owner:
Narne.
FiWbirioZip_,)Left / right side of house, Left /
gfiffeiToi building, Under deck
Address (lf different frnm location)
City/Town
1. Date of Pumping
3. Type of system:
0 Other (describe):
Date
Cesspool(s)
Telephone Number
2. Quantity Pumped:
Gallons
optic Tank El Tight Tank
4. Effluent Tee Filter present? 0 Yes
5. Condition of System:
If yes, was it cleaned? Yes cJ No,
6. System Pumped By:
Neil Bateson
Name
Bateson Enterprises Inc
Company
7. Lo
F5821
Vehicle License Number
e- contents were disposed:
Lowell Waste Water
ign Date
t5forrr4.doc, 06/03
System Pumping Record 0 Page 1 of 1