HomeMy WebLinkAboutSeptic Pumping Slip - 44 CRICKET LANE 10/16/2017Commonwealth of Massachusetts
City/Town of
System Pumping. Record
Form 4
0 C 1 6 017
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 ystern 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 i. h rear of hous Left / right side of house, Left /
Right side of building, Left / Right frOnt of buildirig, Le TRight rear Of building, Under deck
Address
6-6-Nc A-- LidN
City/Town
2. System Owner:
State Zip Code
Name.
Address (if different ion)
City/Town
State
(63 3 Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping
Date
2. Quantity Pumped: Gallons
3. Type.of system 0 Cesspool(s) eptTight Tank ic Tank
0 Other (describe):
4. Effluent Tee Filter present? 6-1_] No If yes, was it cleaned?
" 5. Condition of Sy em:
6: System Pumped By: kl\C>cs
Neil. Batesbn..
' Name
Bateson Enterprises Inc
Company
7. Location Where contents -were disposed:
a I_
.66
El No,
(-e-k_AILsk (c)--ccAm_, tz3
F5821
Vehicle License Number
f
Sform4.doc• 06/03 System Pumping Record • Page 1 of 1