HomeMy WebLinkAboutSeptic Pumping Slip - 128 MILL ROAD 10/16/2017Commonwealth of Massachusetts
City/Town of
System Pumping Record
Form 4
OCT 0 2011
OF NORTH ANDOVER
.1[171 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, Left / Right rear of hous rghj of house/Left /
Right side of building, Left / Rfght front of buildirig, Left / Right rear of building, Underdeck
"—
Address
Vc
City/Town
2. System Owner
State
Zip Code
Narrle.
Address (if different from location)
City/Town '
Code
Telephone Number
B. Pumping Record
1. Date of Pumping
3. Typeof system':
Other (describe):
Date
2. Quantity Pumped:
Gallons
Cesspool(s) LSeptic Tank 0 Tight Tank
4. Effluent Tee Filter present? Ei Yee
' 5. Condition of System:
CA.
If yes, was it cleaned? Ej Yes C] No,
6: System Pumped By:
Neil Bateson
• Name
Bateson Enterprises Inc
Company
7. Loctiqwflere contentsmere disposed:
S. Lowell Waste Water
F5821
Vehicle License Number
gntufe. Haue Date
5form4.doc. 06/03 System Pumping Record • Page 1 of 1