HomeMy WebLinkAboutSeptic Pumping Slip - 49 ORCHARD HILL ROAD 6/17/2017Cornmonwealth of Massachusetts
City/Town
System Pumping Record
Form 4
ECE V
Jot, 011
TOWN OF NORTH ANDOVER
HEALTH DEPARThaNT
DEP has provided this formfor 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 ystem 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 / Rightff6ipf buildin Left / Right rear of building, Under deck
Address
City/Town
•q
2. System Owner:
A)eN
State Zip Code
Name.
Address (if different from location)
City/Town
A
State(
79
Telephone Number
B. Pumping Record
1. Date of Pumping
3. Type -of system: 0
Other (describe):
Date
Cesspool(s)
2. Quantity Pumped:
Gallons
Tank 0 Tight Tank
4. Effluent Tee Filter present? 0 Yes EF-T If yes, was it cleaned? 0 Yes El No,
" 5. Condition of System:
6: System Pumped By:
Neil. Batesbn •
Name
Bateson Enterprises Inc.
Company
7. Locatiojwbre contents were disposed:
a S. Lowell Waste Water
F5821
Vehicle License Number
Sign Date
5form4.doc• 06/03 System Pumping Record • Page 1 of 1