HomeMy WebLinkAboutSeptic Pumping Slip - 292 REA STREET 6/16/2017Commonwealth of Massachusetts
City/Town of
System Pumping. Record
Form 4
C V
JUL 0 5 ?Ol
T 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 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, Left ighi fear of houijAeft/ right side of house, Left /
Right side of building, Left / Right front of building, Lft / Right rear of building, Under deck
Address
City/Town
2. System Owner
N rpe
Address (if different from location)
City/Town
State
Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping
Date
-7 2. Quantity Pumped:
•
Gallons
3. Typepf system: EI Cesspool(s) Septic Tank 0 Tight Tank
0 Other (describe):
4. Effluent Tee Filter present? 0 Yes h No If yes, was it cleaned? 0 Yes 0 No,
" 5. Condition of System:
6: System Pumped By:
Neil. Bateson
Name
Bateson Enterprises Inc
Company
7. L,9oatiQiyhere contents were disposed:
S Lowell Waste Water
F5821
Vehicle License Number
signHaulej 1 Date
t5fom.14.doc• 06/03 System Pumping Record • Page 1 of 1