HomeMy WebLinkAboutSeptic Pumping Slip - 124 STONECLEAVE ROAD 9/26/2017 Commonwealth of Massachusetts
RECOVED
City/Town of t
aSystl m Pumping.Record 2 6709
r`... Fors nl 4 TOWN OF NORTH ANDOVER
HEALTH p pARTm NT
DEP has provided this form for use-by local Boards of Health. Other forme maybe bsed, but the 1
information,must be substantially the same as that provided here. Before using.this form,check with your
local Board of Health to determine the farm they use. The System Pumping Record must be submitted to
the local Board of Health or other approving authority.
A. FacMty Informlation -
1. System Location; Loft I Right front of nous -L„60 Righ re�ar of house IefE/right side of house, Left/
Right side of building, Left/Right front of building, Left/Rlg rear of building, Under deck
Address
cvrown State - Zip Code r
2. System Owner.
Pa 44
Mame'
• i
Address(if different from location)
i
City/Town Stater Zip Code ;
Telephone Number
F.
. Pumping Rpcord
1. Date of Pumping Date — Quantity Pumped: --� --=�
3. Type-of system'. Cesspool(s) Septic Tank ❑ Tight Tank
. I
Other(describe).
t
4. Effluent Tee Filter present? ® Yes No If yes, was it cleaned? ® Yes ® No,
6. Condition of System:
0CV1_\ O
6. System Pumped By:
Neil.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Location.,where contents were disposed:
Lowell Waste Water
I NiSA
F
Sign a Haule Date
t
l5form4.doc•06/03 System Pumping Record•Page 7 of 1