HomeMy WebLinkAboutSeptic Pumping Slip - 66 JAY ROAD 9/7/2017 RECEIVED
Commonwealth of Massachusetts
Q City/Town of . p SP 0 7 2017
�;�
SY.4term Pumping.Record OF NORTH ANDOVER
Form 4 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 authorlty.
A. Facility, Informlation
. M
1. System Location: Left Right front of House eft 1 Right rear of house, Left/right side of house, Left I
Right side of building, Le T iig- ran i�ing, Left I Right rear of building, Under deck
Address �f
Citw I own State Zip Code
2. System Owner. `
Mame.
Address(if different from location)
CityfTown ' State Zip Code
Telephone Number r
Pumping Racord
1. Cate of Pumping � � ( � Quantity Pumped: �0 �
bate Gallons ,
3. Type-of system: Cesspool(s) Septic Tank El Tight Tank Y
[� Other(describe):
4. Effluent Tee Filter present? ❑ Yep No If yes,was it cleaned? ® Yes r-1 No,
5. Condition of System:
6.- System Pumped By:
Nell,Bateson F6821
Name Vehicle License Number
Bateson Enterprises Inc-
Company
7. Lacet n wit a con en disposed:
. - t
CLS. Lowen Waste Water
Sign a Haule Cate
Worm4.doc•06103 System Pumping Record•Page 1 of 1