HomeMy WebLinkAboutSeptic Pumping Slip - 65 SUGARCANE LANE 6/28/2017CornmonWepith of Massachusetts
ECE1VED
City/Town of
System Pumpipg_Record ,. U 5 7017
Form 4 '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 ystern 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 &AcJ-
s,
City/Town State Zip Code
2. System Owner:
Name
Address (if different from location)
City/Town
State Zip Code
Telephone Number
B. PumpingRecord
-I 7
1.
Date of Pumping 2. Quantity Pumped:
Date Gallons
3. Type•of system: 0 Cesspool(s) eptic Tank El Tight Tank
CI Other (describe):
4. Effluent Tee Filter present? 0 Yap g-ta-cr If yes, was it cleaned? 0 Yes 0 No,
" 5. Condition ofSystem:
6: System Pumped By:
Nefl Batesbn •
Name
Bateson Enterprises Inc
Company
7. Locatio4 e contents were disposed:
Lowell Waste Water
F5821
Vehicle License Number
Si Hauler( Date
t5form4.doc• 06/03
System Pumping Record • Page 1 of 1