HomeMy WebLinkAboutSeptic Pumping Slip - 81 BRADFORD STREET 10/16/2017Cornmonwealth of Massachusetts
City/Town of. •
System Pumping.Record 061 6 ?DU
/
Form 4 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
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: Leftd-iloht front of hotse, Left / Right rear of house, Left/ right side of house, Left /
Right side of building, Left / Right faint of building, Left / Right rear of building, Under deck
Address
City/Town
2. System Owner:
Th
State Zip Code
Name
Address (if different from location)
City/Town
Telephone Number
•B. Pumping Record
1 Date of Pumping
3. Typeof system':
0 Other (describe):
4. Effluent Tee Filter present? 0 Yes If yes, was it cleaned? Ej Yes 0 No,
Date
Cesspool(s)
2. Qua_ty nti Pumped:
Gallons
cat
eptic Tank 0 Tight Tank
Condition of System: k _
6; System Pumped By:
Neil BatesOn
Name
Bateson Enterprises Inc
Company
7. Locgon.vere contents were disposed:
at. \ Lowell Waste Water
F5821
Vehicle License Number
t5form4.doc• 06/03 System Pumping Record • Page 1 of 1