HomeMy WebLinkAboutSeptic Pumping Slip - 195 CANDLESTICK ROAD 9/26/2017Cornmonwealth of Massachusetts
•City/Town of.
System Pumping. Record
Form 4
EP 26'2017
TOWN OF NORTH ANDOVER
HEALTH DEPARTMENT
DEP has provided this form. for use43y local Boards Of Health. Other forms may be used, but the
informationmust 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 Inforniatiop
1. System Location: Left / Right front of house, Left / Right rear of house, Left / right side of house, Left /
Right side of building, Left / Right faint of building, Left / Right rear cif building, Under deck
Address ?c)
City/Town
2. System Owner
Name
Address (if differentfrom location)
P)c) s&-e
City/Town
Sta
ZiCode
Telephone Number
01,
•B. Pumping Record
1. Date of Pumping 2. Quantity Pumped:
Date Gallons
3. Type.of system': 0 Cesspool(s) erSigTank 0 Tight Tank
0 Other (describe):
4. Effluent Tee Filter present? El Yes o If yes, was it cleaned? 0 Yes El No,
5. Condition of SysterrE_
C C
6: System Pumped By:
Neil Bateson
Name
Bateson Enterprises Inc
Company
7. Locatinwere contents were disposed:
irifte‘
Signt e Haul
Lowell Waste Water
F5821
Vehicle License Number
Date
t5form4.doc 06/03 System Pumping Record • Page 1 of 1