HomeMy WebLinkAboutSeptic Pumping Slip - 42 JAY ROAD 9/26/2017Commonwealth of Massachusetts
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CitWTown of . .
System Pumping. Record sr]) 2 ti zoi i
Form 4 TOWN OF NORTH ANDOVER
ARTMENT
HEALTH
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City/Town State Zip Code
2. System Owner:
State6
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Telephone Number , 4
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B. Pumping Record
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1. Date of Pumping
Date 2. Quantity Pumped: 1 •
Gallons
3. Type -of system': 0 Cesspool(s) eptic Tank 0 Tight Tank • -,
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 side of building, Le
Neap'
Address (if different from location)
City/Town '
Left / Right rear of house, Left / right side of house, Left /
uildirig, Left / Right rear of building. Under deck
0 Other (describe):
4. Effluent Tee Filter present? 0 Yes Er If yes, was it cleaned? 1:1 Yes E] No,
5. Condition of §)fstem: A
vj
6. System Pumped By:
Neil Batesbr:i
Name
Bateson Enterprises Inc
Company
7. Location whe contents•were disposed:
F5821
Vehicle License Number
15forrn4.doc• 06/03 System Pumping Record • Page 1 of 1