HomeMy WebLinkAboutSeptic Pumping Slip - 66 COLONIAL AVENUE 10/16/2017Commonwealth of Massachusetts
City/Town of
System Pumping Record
Form 4
OCT 1 6 2017.
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 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 Locatio . Left ight of_hou,teft/ Right rear of house, Left/ right side of house, Left /
Right side of bui ing, Left / Right fronroTbuildirig, Left / Right rear cif building, Under deck
City/Town
2. System Owner
State
olJc— be_A'J
Name'
Address (if different from (ocation)
City/Town '
State
Zip C
-
Telephone Number
B. Pumping Record
1. Date of Pumping
3. Typeof systemt El Cesspool(s) eptic Tank 0 Tight Tank
cc, ±17
6
0 Other (describe):
Date
2. Quantity Pumped:
Gallons
4. Effluent Tee Filter present? 0 Yes Ea,446
' 5. Condition of System:
6: System Pumped By:
Bateson
Name
Bateson Enterprises Inc
Company
7. Loca ere contents were disposed:
Lowell Waste Water
If yes, was it cleaned? El Yes 0 No,
F5821
Vehicle License Number
5form4.doc. 06/03 System Pumping Record • Page 1 of 1