HomeMy WebLinkAboutSeptic Pumping Slip - 25 HOLLOW TREE LANE 10/16/2017Commonwealth of Massachusetts
City/Town of
System Pumping. Record
Form 4
OCT 1 (5 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 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(Lft Rig t of tious Left / Right rear of house, Left / right side of house, Left /
Right side of buil eft / RigWfi�1iff building, Left / Right rear of building, Under deck
Address
City/Town
2. System Owner:
uLoc&ITc
State •Zip Code
Ce'
Name'
Address (if different from location)
City/Town
Statt- 4.06 Zip Code
Telephone Number
B. Pumping Record
PC;
1. Date of Pumping
Date
2. Quantity Pumped:
Gallons
3. Type.of system 0 Cesspoot(s) Ertic Tank 0 Tight Tank
Other (describe):
4. Effluent Tee Filter present? 0 Yes [3"1N-O If yes, was it cleaned? 0 Yes El No,
5. Condition of Byste :
0 '‘i\t-oki 1Aity( N
6: System Pumped By:
Neil Batesbri
" Name
Bateson Enterprises Inc
Company
7. Locatiovbre contents were disposed:
Lowell Waste Water
F5821
Vehicle License Number
Signh4e c Hauei(Date
5forrn4.doc• 06/03 System Pumping Record • Page 1 of 1