HomeMy WebLinkAboutSeptic Pumping Slip - 67 ROCKY BROOK ROAD 10/25/2017 Comrnonwe (th of Massachusetts
RtCEIVED
QtY/Town of .
.,
.:
r
Sy tem Pumping.Record C 01
...
Form. 4 TOWN F NORTH ANDOVER
. . % HEALTH DEPARTMENT
DEP has provided this form for use-by local Boards of Health. Other forms maybe"used, but the
Information'must be substantially the same as that provided here. Before using.this form., '
heck with your t
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 Locatio Left I rq' of hi se;Left/Right rear of house, Left/right side of house, Left/
Ri ht side of bu 1 1n( eft/ front of buildin Leg g;L g, ft/Right rear of building, Under deck
Address
City/rown State Zip Code
2; System Owner:
Name`
Address(if different from location)
City/rown � State• p�Co e
f �`l
Telephone Number
,i
.B. Pumping Rpcord
(
1. ®ate of Pumping Date 2. Quantity Pumped:
Gallons
3. Type-of system: ❑ Cesspool(s) tic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes o If yes, was it cleaned? ® Yes ❑ No,
5. Condition ofSyste
6. System Pumped By:
Neil.Bateson F5821
Name Vehicle License Number
Bateson Ehterprises Inc
Company
7. Loca" n where contents-were disposed:
G L S: Lowell Waste Water
17
Slgn t e cf Haute pate
5forrn4.doe*06/03 System Pumping Record•Page 1 of 1
