HomeMy WebLinkAboutSeptic Pumping Slip - 213 CARLTON LANE 6/19/2017Form 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 tame 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 iocatiqrritiig frorit ciliof_sd, Left/ Right rear of house, Left / right side of house, Left /
Right side of bui1d1iig, Left / ron of building, Left / Right rear cif building, Under deck
Address
City/Town
2. System Owner:
State Zip Code
Name
Address (if differentfrom location)
City/Town
State --
Zip de
Telephone Number
B. Pumping Record
Commonwealth of Massachusetts
ECEIVED
City/Town of
System Pumping. Record ii)11
TOWN OF NORTH ANDOVER
HEALTH DEPARTMENT
--(
1. Date of Pumping
Date
2. Qua tity Pumped:
Gallons
3. Typeof system': 0 Cesspool(s) 0 Septic Tank El Tight Tank
Other (describe):
4. Effluent Tee Filter present?
5. Conditiot of System:
6: System Pumped By:
Neil. Batesbr2 •
• Name
Bateson Enterprises Inc
Company
7. Loca •. ere contents were disposed:
No If yes, was it cleaned?
at. S.j Lowell Waste Water
Sign
F5821
0 No,
Vehicle License Number
Date
5form4.doc- 06/03 System Pumping Record • Page 1 of 1