HomeMy WebLinkAboutSeptic Pumping Slip - 111 CHRISTIAN WAY 7/6/2017Commonwealth of Massachusetts
City/Town of . •
System Pumping. Record J1IL
Form 4 TOWN 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.
c
. A. Facility. Information
. .
1. System Location: Left / Right front of house, Left/ igbtrrofhovs, Left / right side of house, Left /
Right side of building, Left / Right front of building, Left / Right rear Of building, Under deck
Address
City/Town
2. System Owner:
Address (if different from locat on)
City/Town
State
State
Zip Code
Telephone Number
B. Pumping Record CP -
1. Date of Pumping 2. Quantity Pumped:
Date Gallons
3. Type.of system': El Cesspool(s) 0-8giank 0 Tight Tank
0 Other (describe):
4. Effluent Tee Filter present? El Ye.s
5. Condition lof ystem: /
if yes, was it cleaned? 0 Yes 0 No,
6: System Pumped By:
Neil Bateson
Name
Bateson Enterprises Inc
Company
7. Location contents were disposed:
S. Lowell Waste Water
F5821
Vehicle License Number
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