HomeMy WebLinkAboutSeptic Pumping Slip - 89 LOST POND LANE 10/16/2017Commonwealth of Massachusetts
City/Town at . •
System Pumping. Record
Form 4
ECEI
TOWN OF NORTH ANDOVER
HEALTH DEPARTMENT
DEP has provided this form. for usetif 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 ront of house, Left/ Right rear of house, Left/ right side of house, Left /
Right side of building, LTRijftfrfir�tbiiiIdirig, Left / Right rear of building, Under deck
Address
City/Town
• • Ca-9 L
State
2. System Owner
Zip Code
Na
Address (if different from location)
City/Town
Telephone Number
B. Pumping Record
1. Date of Pumping 2. Quantity Pumped:
Date Gallons
Type -of system'. 0 Cesspool(s) Septic Tank 0 Tight Tank
0 Other (describe):
4. Effluent Tee Filter present? 0 Yes Er
' 5. Condition of System:
If yes, was it cleaned? Yes 0 No,
6: System Pumped By:
Neil Bateson
Name
Bateson Enterprises Inc
Company
7. Loca re contents were disposed:
Lowell Waste Water
Si n e Haule
F5821
Vehicle License Number
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