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 15form4.doc• 06/03 System Pumping Record • Page 1 of 1