HomeMy WebLinkAboutSeptic Pumping Slip - 37 OLYMPIC LANE 10/2/2017Cornmonwe Ith of Massachusetts
City/Town of.
System Pumping. Record
Form 4
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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
information must be substantially the same as that provided here. Before using .this form, check with your
local Board of Health to determine the forrn 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, Leftrkiitlt rear of hous. -)Left/ right side of house, Left /
Right side of building, Left / Right front of building, Left / Right rear cif building, Under deck
Address
City/Town
2. System Owner:
Th
LCtiat'.
State Zip Code
Narrie.
Address (if different from Location)
City/Town '
State Zip Code
Telephone Number
B. Pumping Record
g(o
1. Date of Pumping . Quantity Pumped:
Date Gallons
3. Typeof system: 0 Cesspool(s) Septic Tank 0 Tight Tank
El Other (describe):
" 5. Condition of System:
Effluent Tee Filter present? 0 Yep
6. System Pumped By:
Neil Bateson
' Name
Bateson Enterprises Inc
Company
7. Location_where contents were disposed:
owell Waste Water
Sign Neu!
If yes, was it cleaned? 0 Yes 0 No,
F5821
Vehicle License Number
Date
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