HomeMy WebLinkAboutSeptic Pumping Slip - 438 SUMMER STREET 6/28/2017 (2)Cornmonwepith of Massachusetts
City/Town of.
System Pumping. Record
Form 4
ECEIVED
JUL 0 5 ? 0 1 (
Towt4 OF NORTH ANDOVER
DEP has provided this form. for usaby local Boards Of Health. Other forms maplitiggiKSIG
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 hous , Left / right side of house, Left /
Right side of building, Left / Right front of building, Left / Right rear of building, Under deck
Address
2. System Owner:
Name'
Address (if different from location)
City/Town
State Zip Code
State.
Z p Code
Telephone Number
B. Pumping Record
1. Date of Pumping 2. Quantity Pumped:
Date Gallons
3. Type -of system': El Cesspool(s) ' 13- ei-S4:Tank 0 Tight Tank
0 Other (describe):
4. Effluent Tee Filter present? 0 Y 1 If yes, was it cleaned? 0 Yes 0 No,
' 5. Condition of System:
Poro,v.„}( (re/kJ
6: System Pumped By:
Neil Bateson -
• Name
Bateson Enterprises Inc
Company
7. Location where contents were disposed:
Lowell Waste Water
F5821
Vehicle License Number
Sign e qt Haulei•(Date
t5form4.doc• 06/03 System Pumping Record • Page 1 of 1