HomeMy WebLinkAboutSeptic Pumping Slip - 41 CROSSBOW LANE 10/16/2017E
Commonwealth of Massachusetts
City/Town of.
System Pumping. Record
Form 4
OCT 6'2,0
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 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, )/ RIghjr of licius.erteft/ right side of house, Left /
Right side of building, Left / Right front of building, Left / Right rear cif building, Under deck
Address
4-(( C(o%b3 tv
City/Town State
2. System Owner.
Zip Code
Name.
Address (if different fro
location)
City/Town '
State Zip Code
cfect{ er5q)
Telephone Number
•B. Pumping Record
n
1. Date of Pumping
Dat10b
3. Typebf system D Cesspool(s)
Other (describe):
uantity Pumped:
Gallons
eptic Tank 0 Tight Tank
•
4. Effluent Tee Filter present? El Yes No
" 5. Condition of System:
6. System Pumped By:
Neil Batesbn
Name
Bateson Enterprises Inc
if yes, was it cleaned? ED Yes 0 No,
cff
Company
7. Location where contents were disposed:
Lowell Waste Water
Sin Haul
F5821
Vehicle License Number
5forrn4.doc• 06/03 System Pumping Record • Page 1 of 1