HomeMy WebLinkAboutSeptic Pumping Slip - 32 EQUESTRIAN DRIVE 6/23/2017Commonwealth of Massachusetts
City/Town of.
System Pumping. Record
Form 4
ECEIVED
JUL (15
TOWN OF NORTH ANDOVER
HEALTH DEPARTMENT
DEP has provided this form. for usaby local Boards Of Health. Other forms may be -used, but the
information must be substantially the same as that provided here. Before using.this forrn, 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 house,
Right side of building, Left / Right front of bukfg, Left / Right rear of building, Under deck
City/Town
2. System Owner:
Name
Address (if different from Location)
City/Town
State
7
Telephone Number
B. Pumping Record
1. Date of Pumping
3. Typeof system':
Ei Other (describe):
Date
Cesspoot(s)
'7 •
2. Quantity Pumped:
ight fecalorhouie?Left/ right side of house, Left /
Gallons
eptic Tank Ei Tight Tank
I yes, was it cleaned?
" 5. Condition of System:
4. Effluent Tee Filter present? J Yes [ZIA()
\ A
E3 Yes Ej No,
6: System Pumped By:
Neil. Bateson
' Name
Bateson Enterprises Inc.
Company
7. Location Where contents -were disposed:
Lowell Waste Water
Signtufe c Haule
F5821
Vehicle License Number
Date
5form4.doc 06/03 System Pumping Record • Page 1 of 1