HomeMy WebLinkAboutSeptic Pumping Slip - 146 DEER MEADOW ROAD 6/28/2017Commonwealth of Massachusetts
City/Town of
System Pumping Record
Form 4
ECEIVED
LJUI 05 Z011
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 System Pumping Record must be submitted to
the local Board of Health or other approving authority.
• A. Facility Information
1. System Location: Left / ont of hous , Left/ Right rear of house, Left/ right side of house, Left /
Right side of building, Left / Right front of building, Left / Right rear cif building, Under deck
Address Li 6.2
City/Town
2. System Owner
t4eIU‘
/4-
State Zip Code
Name'
Address (if different from location)
City/Town
State&
e?
Telephone Number
B. Pumping Record
1. Date of Pumping
3. Type system':
Other (describe):
•
Date
.
2. Quantity Pumped:
Gallons
Cesspool(s) Dptic Tank Ei Tight Tank
4. Effluent Tee Filter present? es EJ No
5. Condition o tem:
If yes, was it cleaned? 1:3-1:1
6; System Pumped By:
Neil Bateson
Name
Bateson Enterprises Inc.
Company
7. Location Jee contents -were disposed:
Lowell Waste Water
F5821
Vehicle License Number
t5forrn4.cloc• 08/03 System Pumping Record • Page 1 of 1