HomeMy WebLinkAboutSeptic Pumping Slip - 63 BRADFORD STREET 9/26/2017v
Commonwealth of Massachusetts
City/Town of.
System Pumping. Record
Form 4
c
P 2 6 201/
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 form they use. The ystem 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(Legi Righ
Right side of building, Left / Right front of building, Left /
g
r of ke'-Left/ right side of house, Left /
ear o building, Under deck
Address
City/Town
2. System Owner:
Ca (
(4e, I-46
v-e(
State
Zip Code
Narrie'
Address (if different from location)
City/Town '
State.
tic (
Telephone Number
Zip Code
B. Pumping Record
1. Date of Pumping
Date
3. Type of system': Ej
EI Other (describe):
uantity Pumped:
Cesspool(s) Septic Tank Ej Tight Tank
4. Effluent Tee Filter present? 0 Yap
" 5. Condition of System:
6: System Pumped By:
Neil. Bates -on
' Name
Bateson Enterprises Inc
olvfi q.( 1,
Company
7. Loa,rt-wtere contents were disposed:
at_ Lowell Waste Water
Sign Fibula
If yes, was it cleaned? 0 Yes 0 No,
F5821
Vehicle License Number
? 7
Date
$
t5form4.doc• O6/03 System Pumping Record • Page 1 of 1