HomeMy WebLinkAboutSeptic Pumping Slip - 59 EVERGREEN DRIVE 10/2/2017Cornmonwepith of Massachusetts
City/Town of
System Pumping. Record
Form 4
* )CT 2. ?(I) 1 7
TOW 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, Left / Right rear of house, Left / right side of house, Left /
Right side of building, Left / Right front of building, Left / Right rear Of building, Under deck
Address
City/Town
2. System Owner:
State Zip Code
r.
Name'
Address (if different from location)
City/Town State
p ode
Telephone Number
B. Pumping Record
1 Date of Pumping
3. Type -of system': El
Other (describe):
Date
Cesspool(s) Tight Tank
2. Quantity Pumped:
Gallons
4. Effluent Tee Filter present? 0 Yes If yes, was it cleaned? 0 Yes El No,
Condition of System:
2fl
(4,cLee__ \
6; System Pumped By:
NeilBateson
Name
Bateson Enterprises Inc
Company
7. Location where contentswere disposed:
owell Waste Water
F5821
Vehicle License Number
15form4.doc• 06/03 System Pumping Record • Page 1 of 1