HomeMy WebLinkAboutSeptic Pumping Slip - 11 PURITAN AVENUE 6/19/2017Commonwealth of Massachusetts
City/Town of
System Pumping. Record
Form 4
ECEIVED •
J.0 0 ?in /
TOWN OF NORTH ANDOVER
HEALTH DEPARTMENT
DEP has provided this form for use.by local Boards 'Of Health. Other forms may be bsed, but the
informationmust 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.
. A. Facility Information
1. System Locati : Lerjar ont of hou e, Left / Right rear of house, Left/ right side of house, Left /
Right side of b fir.Left TRtgflrf?iif of buildirig, Left / Right rear of building, Under deck
Address
LL
2. System Owner:
Name.
Address (if different from location)
City/Town
Statec--
cI
Zip Code
Telephone Number
B. Pumping Record
(7
1. Date of Pumping Date 2. Quantity Pumped:
Gallons
3. Typeof system 0 Cesspool(s) eptic Tank 0 Tight Tank
Other (describe):
4. Effluent Tee Filter present? Ej Yes [2-14ii If yes, was it cleaned? 0 Yes EJ No,
" 5. Condition of Systerix.....T—
k
6: System Pumped By:
Neil. Bateson •
Name
Bateson Enterprises Inc
Company
7. LocaJpn-where contents were disposed:
at. a
F5821
Vehicle License Number
5form4.doc• 06/03 System Pumping Record • Page 1 of 1