HomeMy WebLinkAboutSeptic Pumping Slip - 295 REA STREET 10/16/2017Cornmonmiegith of Massachusetts
City/Town of. •
System P-umpirig_Record
Form 4
E6E V
(WI '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 Location: Left / Right front of house, LeftL.R trear of house ft/ right side of house, Left /
Right side of building, Left / Right frOnt of building, Left Might rear oT building, Under deck
City/Town
2. System Owner:
State
Name
Address (if different from location)
City/Town '
State-
(Z) 77
Telephone Number
B. Pumping Record
1. Date of Pumping
3. Type.of system 0 Cesspool(s) Ej--S-e;tic Tank 0 Tight Tank
Other (describe):
2. Quantity Pumped:
Date Gallons
4. Effluent Tee Filter present?
' 6. Condition o
LJ No If yes, was it cleaned?
-72rz-uki 1uLe (A_
6: System Pumped By:
Neil Batesdn
Name
Bateson Enterprises Inc
Company
7. Loc here contents were disposed:
•
at_ a
ig Hauls
owell Waste Water
F5821
13-`1 No,
Vehicle License Number
Date
aorm4.doci. 06/03 System Pumping Record • Page 1 of 1