HomeMy WebLinkAboutSeptic Pumping Slip - 59 SUNSET ROCK ROAD 6/28/2017Commonwealth of Massachusetts
•City/Town of .
System Pumping. Record
Form 4
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.
• RECEIVED
U.51011
TOWN OF NORTH ANDOVER
• HEALTH DEPARTMENT
• A. Facility Information
1. System Location: Left / Right front of house / Rightr housiN Left / right side of house, Left /
Right side of building, Left / Right front of building, Left / Rig t rear &building, Under deck
Address
City/Town
2. System Owner:
Stet')
Zip Code
Addressdifferent from location)
City/Town "
State
(9
Telephone Number
Zip Code
5
B. Pumping Record
1. Date of Pumping
21 2. uantity Pumped:
Date
Gallons
3. Type•of system: El Cesspool(s) 0/Septic Tank 0 Tight Tank
Other (describe):
4. Effluent Tee Filter present? 0 Yap
" 5. Condition of System:
6: System Pumped By:
Neil. Batesbn
Name
Bateson Enterprises Inc
Company
7. Locatipiiwhere contents were disposed:
Lowell Waste Water
If yes, was it cleaned? 0 Yes ri No,
F5821
Vehicle License Number
t5form4.doc• 06/03 System Pumping Record • Page 1 of 1