HomeMy WebLinkAboutSeptic Pumping Slip - 55 LOST POND LANE 6/26/2017Commonwealth of Massachusetts
•City/Town of CE1V
System Pumpipg.Record
Form 4
TOWN OF NORTH ANDOVER
DEP has provided this form for use local Boards of Health. Other form' 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.
JUI: 0 5 ?0 1
• A. Facility, Information
1. System Locatio Left Rigbt af house Left/ Right rear of house, Left./ right side of house, Left /
Right side of buil ing, Left / R!ffifl5fSiIdirig, Left / Right rear of building, Under deck
Address
City/Town
2. System Owner:
State
(1`
Zip Code
Name
Address (if different from location)
City/Town
StIe
ZipCod
Telephone Number
B. Pumping Record
1. Date of Pumping
Date
3. Type -of system": Cesspool(s)
Other (describe):
•
2. Quantity Pumped: Gallons
rank 1-3 Tight Tank
4. Effluent Tee Filter present? 0 Yes
' 5.
6: System Pumped By:
Bateson
Name
Bateson Enterprises Inc.
Company
7. Location where contents -were disposed:
G.LS.
Lowell Waste Water
If yes, was it cleaned? D Yes D No,
.
F5821
Vehicle License Number
Hauler( Date
t5form4.doc• 06103 System Pumping Record • Page 1 of 1