HomeMy WebLinkAboutSeptic Pumping Slip - 50 WILD ROSE DRIVE 9/11/2017 Commonwealth of Massachusetts
RECEIVED
City/Town of .
SY,4tem Pumping.Record �� :��� 0 7 2017
Form 4 TOWN OF NORTH ANDOVW
HEALTH DEPARTMENT
DEP has provided this form for use-by local Boards of Health. Other forms maybe"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/ f kieusd, Left/Right rear of house, Left I right side of house, Left/
Right side of building, Left/Right front of building, Left/Right rear of building, Under deck
Address
cityfrown State - Zip Code ('
2. System Owner. R
Name
Address(if different from location)
i
Cityfrown State ZIP C12)
;
P "Y
Telephone Number " t
. Pumping Record _
c P--(r7 .
1. Date of Pumping 2. Quenti Pumped:
Date p Gallons ;.
3. Type-of system: ❑ Cesspool(s) ❑ Septic Tank ❑ Tight ank
ther(describe): I C`
4. Effluent Tee Filter present? ❑ Yes ❑ No If yes,was it cleaned? ❑ Yes ❑ No,
5. Condition of System:
6: System Pumped By:
Ne€l,Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc-
Company
7. Locatio ere contents were disposed:
�L
SIR Lowell Waste Water (( j
Sign @ llaule Date
t5form4.doc•08/03 System Pumping Record*Page 9 of 1