HomeMy WebLinkAboutSeptic Pumping Slip - 221 CAMPBELL ROAD 9/26/2017 Commonwealth of Massachusetts RECEIVED
.CRY/Town of . � 1
y/ tem Pt-um p . .Record TOWN OF NORTH ANDOVER
FQrm 4 HEALTH DEpARTMENT
DEP has provided this form far use-by local Boards of Health. Other form's 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 submltte�d to
the local Board of Health or other approving authority.
A. Facit%ty. Informiation
1. System Location: Left k t of thous
from a Left/Right rear of house, Left/right side of house, Left/
Right side of building, Left/Right front a uildirig, Left/Right rear of building, Under deck
Address10,4
r
City/rown State - Zip Code
2. System Owner.
UO)
Name'
Address(if different from location)
City/Town ' '. State '•" Zip Code
F
Telephone Number `
Pumping Record
1. Cate of Pumping Date 2. Quantity„Pumped: Daltons
3. Type-of system: El Cesspool(s) eptic Tank ® Tight Tank
Other(describe):
4. Effluent Tee Filter present? ® Yes [3, If yes,was it cleaned? ❑ Yes [I No,
” 6. Condition of System: A.., �� P ._ •
6. System Pumped By:
Nell.Bateson F5821
Name Vehicle tteense Number
Bateson Enterprises Inc
Company
7. Locationw ere contentawere disposed: t
.L Lowell Waste Water l
Sign a Haut Date
t5form4.doo•08103 System Pumping Record•Page 1 of 1