HomeMy WebLinkAboutSeptic Pumping Slip - 61 GRANVILLE LANE 10/16/2017Cornmonwealth of Massachusetts
City/Town of.
System Pumping Record
Form 4
OCT.
TOWN OF NORTH ANDOVER
HEALTH DEPARTMENT
DEP has provided this forrn. for usern local Boards Of Health. Other forms may bebsed, but the
information must be substantially the tame as that provided here. Before using.this foffn, 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 Inforrilatiop
1. System Locatio Le Right
Right side of but in ,Left / Filg
612-A. N V I •
Address
kJ
, Left/ Right rear of house, Left/ right side of house, Left /
uilding, Left / Right rear of building, Under deck
City/Town State Zip Code
2. System Owner:
Name
Address (if different from location)
City/Town
State Zip Code
7 — 0 Cci
Telephone Number
•B. Pumping kpcord
1. Date of Pumping Date 2. Quantity Pumped:
3. Type.of system 0 Cesspool(s) (rd, Septic Tank
0 Other (describe):
4. Effluent Tee Filter present.
" 5. Condition of §-)rstem:
N 02-bv\A-t-,
Gallons
0 Tight Tank
Ye 0 No
If yes, was it cleaned? Yes 0 No,
.
6: System Pumped By:
Neil. Bateson
Name
Bateson Enterprises Inc
Company
7. Location where contents were disposed:
Lowell Waste Water
F5821
Vehicle License Number
5form4.doc• 06/03 System Pumping Record • Page 1 of 1