HomeMy WebLinkAboutSeptic Pumping Slip - 143 DUNCAN DRIVE 7/31/2017Commonwealth of Massachusetts
City/Town of
System Pumping. Record
Form 4
Akt 31 2011
TOWN OF NORTH ANDOVER
HEALTH DEPARTMENT
DEP has provided this form for useliy 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 igharbThous, Left / right side of house, Left /
Right side of building, Left / Right front of bui ding, Left / Rig re r cif building, Under deck
Address
City/Town
2. System Owner:
Name'
Address (if different from location)
City/Town •
State
Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping
Date 2. Quantity Pumped:
3. Type -of system 0 Cesspool(s) ate)tic Tank
EJ Other (describe):
4. Effluent Tee Filter present?
" 5. ConclitisgLof Syste :
6: System Pumped By:
Neil Bateson
• Name
Bateson Enterprises Inc
Gallons
CI Tight Tank
Company
7. Location where-c ntents were disposed:
owell Waste Water
No If yes, was it cleaned? 0—'rerE1 No,
F5821
Vehicle License Number
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