HomeMy WebLinkAboutSeptic Pumping Slip - 27 OAKES DRIVE 10/25/2017 Commonwealth of Massachusetts RECEIVED
City/Town of t
. I
Sy' telll"1 Pumping.Record T.OWN OF NORTH ANDOVER
Form 4
HEAL'11 DEPARTMENT I
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,check with your
local Board of Health to determine the forrn 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 tions , Le i,12ig tear of ho we, Left/right side of house, Left,/
Right side of building, Left/Right front of bul Ing, Left 1�of building, Under deck
Address
City/Town / state Zip Code
2. System Owner:
Name'
Address(if different from location)
cityfrown state1p Code
Telephone Number
. Pumping Keeord
&- (7
1. Cate of Pumping Date 2. Quaon,ti Pumped: Gallons
3. Type-of system: ® Cesspool(s) eptic Tank ❑ Tight Tank `
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes o if yes, was it cleaned? ❑ Yes ❑ No,
5. Condition of Sy to 7
6. System Pumped By:
Neil.Bateson - F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company J
7. Locafionwh9re contents-were disposed: j
Lowell Waste Water
IF
Sign a(ftbuleV Date
t
;5form4.doc•08/03 system Pumping Record=page 1 of 9
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