HomeMy WebLinkAboutSeptic Pumping Slip - 76 GRANVILLE LANE 9/26/2017Commonwealth of Massachusetts
City/Town of.
System Pumping. Record
Form 4
CEW
2 6 ?DI 1
TOWN OF NORTH ANDOVER
HEALTH DEPARTMENT
DE'P 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.
A. Facility Information
•
1. System Location: Left / Right front of house, Left / Right rear of house,Ctiltr- ight 'de hous Left /
Right side of building, Left / Right front of buildirig, Left / Right rear of building, Und&rdcIr
Address
City/Town
2. System System Owner
State Zip Code
ame
Address (if different from location)
City/Town
Stat
Telephone Number
B. Pumping Record
•,, -r7-)- 622
1. Date of Pumping 2. Quantity Pumped:
Date a Ions
3. TypeA)f system: El Cesspool(s) ptic Tank 0 Tight Tank
El Other (describe):
ra'--
4. Effluent Tee Filter present? [::] Yes ( If yes, was it cleaned? 1:1 Yes 0 No,
5. Condition of System
tA4a,i (,(eu
6: System Pumped By:
Nell. Bateson •
' Name
Bateson Enterprises Inc
Company
7. LocaJQpwhe e contents were disposed:
GLS.. LoweliWasteWate
F5821
Vehicle License Number
Sign e. Haui Date
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