HomeMy WebLinkAboutSeptic Pumping Slip - 91 BOSTON STREET 10/16/2017Cornmonwealth of Massachusetts
City/Town of.
System Pumping. Record
Fortin 4
RECO
1 6101'1
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 ystem Pumping Record must be submitted to
the local Board of Health or other approving authority.
A. Facility Information
1. System Location: Left
Right side of building,
Left
Right front o building,
I hi rear of hous
eft / Rig
Left/ right side of house, Left /
rear o building, Under deck
Address
City/Town
2. System Owner:
State
Zip Code
Name.
Address (if different from location)
City/Town
B. Pumping Record
1. Date of Pumping
•
Date
3. Type -of system 0 Cesspool(s) Er‘pic Tank
0 Other (describe):
State
Telephone Number
2. Quantity Pumped:
1:1 Tight Tank
Zip C de
Gallons
•
4. Effluent Tee Filter present? Yep
" 5. Condition of System:
If yes, was it cleaned? 0 Yes El No,
Aeutki(4--e2,_
6.- System Pumped By:
Neil Bates -on
Name
Bateson Enterprises Inc
Company
7. Loctionhere contents were disposed:
Lowell Waste Water
F5821
Vehicle License Number
signtuFe qrHiiJer(Date
t5form4.doc. 0S/03 System Pumping Record • Page 1 of 1