HomeMy WebLinkAboutSeptic Pumping Slip - 287 FOREST STREET 6/23/2017Cornmonwealth of Massachusetts
City/Town of
System Pumping Record
Form 4
RECEIVE
0.5 2-011
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 forrn 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, 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
s4-17_?.5
City/Town
2. System Owner
State
Zip Code
Name'
Address (if different from location)
City/Town '
State
STh
Telephone Number
B. Pumping Record
1. Date of Pumping
Date
cTh- 3--((17
2. Quanti
Pumped:
Gallons
3. Type.of system: 0 Cesspool(s) eptic Tank r] Tight Tank
Other (describe):
4. Effluent Tee Filter present? 0 Yes
Condition of Syste
If yes, was it cleaned? D Yes EJ No,
6: System Pumped By:
Neil. Bates -on •
Name
Bateson Enterprises Inc
Company
7. Locationwhere contents were disposed:
S. Lowell Waste Water
F5821
Vehicle License Number
(
Sign Haul- Date
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