HomeMy WebLinkAboutSeptic Pumping Slip - 125 SAW MILL ROAD 9/26/2017Commonwealth of Massachusetts
City/Town of.
System Pumping. Record
Form 4
$111) 2 6 017
TOWN OF NORTH ANDOVER
HEALTH DEPARTMENT
DEP 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 font' 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, Leftr.
Right rear of housSo Left / right side of house, Left /
Right side of building, Left / Right front of building, ETUTREit rear of building, Under deck
Address
City/Town
2. System Owner:
Name.
Pt; I ( )Stateld ye(
Zip Code
Address (if different from location)
City/Town
State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping —d0 Quantity Pumped:
Da e
Gallons
3. Typeof system*: 0 Cesspool(s) LY Septic Tank El Tight Tank
Other (describe):
E 4. Effluent Tee Filter present? D Yes No i If yes, was it cleaned? 0 Yes 0 No,
5. Condition of pistem:
System Pumped By:
Neil. Bates -loci
Name
Bateson Enterprises Inc
11
Company
7. Lo on Where contents were disposed:
S. Lowell Waste Water
F5821
Vehicle License Number
Sign Haul Date
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