HomeMy WebLinkAboutSeptic Pumping Slip - 103 VEST WAY 10/2/2017If yes, was it cleaned? 0 Yes Ej No,
F5821
Vehicle License Number
1. Date of Pumping
3. Typeof syatem':
El Other (describe):
Commonwealth of Massachusetts
City/Town of
System Pumping Record
Form 4
C, 2 Z 0
TOWN OF NORTH ANDOVER
HEALTH DEPARTMENT
DEP has provided this form. for use.by local Boards Of Health. Other forma may be Used, but the
informationmust be substantially the same as that provided here. Before using.this forrn, 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 might front of hous_eoLeft/ 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
N)eck \A)a
City/Town
2. System Owner:
Name
Address (if different from tocation)
Atn
State
Zip Code
City/Town
B. Pumping Record
a2,- 1'7 2. Quantity Pumped:
Date
Cesspool(s) f. Septic Tank 0 Tight Tank
State
Telephone Number
Zip Code
0 - -7 5'15
4. Effluent Tee Filter present? El Yes
Condition of System:
6; System Pumped By:
Neil. Batesbn •
• Name
Bateson Enterprises Inc
Company
7. Locatjpnhere contentawere disposed:
Lowell Waste Water
t5forrn4.doc• 06/03 System Pumping Record • Page 1 of 1