HomeMy WebLinkAboutSeptic Pumping Slip - 175 OLD CART WAY 9/26/2017Commonwealth of Massachusetts
City/Town of
System Pumping. Record
Form 4
CE V
• • 2011
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
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 Information
1. System Location: Left / Right front of house, Left / Right rear of house, Left /j tsideofhoy, Left /
Right side of building, Left / Right front of building, Left / Right rear of building, 070 er deck
Address • t S 3 CA WO,L1
Ctty/Town State j Zip Code
2. System Owner:
Narrre.
Address (If different from location)
City/Town '
State
gig
o e
Telephone Number
B. Pumping Record
1. Date of Pumping
Date
((-(7
2. Quantity Pumped:
Gallons
3. Type,of system: 0 Cesspooks) c Tank 0Tight Tank
Other (describe):
4. Effluent Tee Filter present? I:: Ves If yes, was it cleaned? 0 Yes El No,
' 5. Condition of system:
( tr„J tfrJa/A
6. System Pumped By:
Neil Batesbn
' Name
Bateson Enterprises Inc
Company
7. Locati contents were disposed:
owell Waste Water
F5821
Vehicle License Number
Sign e. Hauler( Date
t5forrn4.doc• 06/03 System Pumping Record • Page 1 of 1