HomeMy WebLinkAboutSeptic Pumping Slip - 90 SPRING HILL ROAD 10/16/2017Cornmonwealth of Massachusetts
City/Town oi •
System Pumping. Record
Form 4
ECENE
()C. 1 6 2017
TOWN OF NORTH ANDOVER
HEALTH DEPARTMENT
DEP has provided this form for use local Boards of Health. Other forms may be used, but the
informationmust 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/ 1gtit mar of hou ?Left/ right side of house, Left /
Right side of building, Left / Right front of building, LeffTRighTiar of building, Under deck
2. System Owner:
Name'
Address (if different from location)
City/Town '
Telephone Number
t
B. Pumping Record
1. Date of Pumping
Date
2. Quantity Pumped:
Gallons
3. Typeof system': D * Cesspool(s) eptic Tank 0 Tight Tank
Other (describe):
4. Effluent Tee Filter present? No If yes, was it cleaned?
. Condition of System:
No,
6: System Pumped By:
Neil Bateson
Name
Bateson Enterprises Inc.
Company
7. Loc n,yhere contents were disposed:
Lowell Waste Water
F5821
Vehicle License Number
Date
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