HomeMy WebLinkAboutSeptic Pumping Slip - 96 SUGARCANE LANE 10/2/20172 7017 .
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 faun they use. The System Pumping Record must be submitted to
the local Board of Health or other approving authority.
Commonwealth of Massachusetts
Citgrown of. •
System Pumping. Record
Form 4
A. Facility Information
1. System Location: Le orit of hou_ , 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:
-kt
State
Zip Code
Narne
Address (if different from location)
City/Town ' State
B. Pumping Record
Zip Code
Telephone Number
(-C-S
Gallons
3. Typeof system': ECesspool(s) 1:3L-Stic Tank El Tight Tank
0 Other (describe):
1. Date of Pumping Date 2. Quantity Pumped:
[9-------
4. Effluent Tee Filter present? 0 Ye No No If yes, was it cleaned? D Yes 0 No,
" 5. Condition of System: ucic A
6: System Pumped By:
Neff Batesbn •
' Name
Bateson Enterprises Inc
Company
7. Loatio., *FT e contents were disposed:
GL. S. Lowefl Waste Water
F5821
Vehicle License Number
Sign e. Reale W Date
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