HomeMy WebLinkAboutSeptic Pumping Slip - 35 ROCKY BROOK ROAD 10/30/2017Commonwealth of Massachusetts
City/Town of
System Pumping. Record
Form 4
OCT 3 0 ?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
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: Left / Right front of house, Left / Right rear of house, Left , Left /
Right side of building, Left / Right frOnt of building, Left / Right rear of building, Under deck
Address
City/Town
2. System Owner.
State
Zip Code
Narr)e'
Address (if different from location)
City/Town
Stet
(77
Telephone Number
Zip Code
cr.7
B. Pumping Record
r
1. Date of Pumping u ntity Pumped:
Date Gallons
3. Type of system 0 Cesspool(s) Tight Tank
p ic Tank
0 Other (describe):
4. Effluent Tee Filter present? 0 Yap o
5. Condition of System:
If yes, was it cleaned? D Yes El No,
lq).< A
6. System Pumped By:
Neil. Bateson
' Name
Bateson Enterprises Inc
Company
7. on -where contents were disposed:
•
F5821
Vehicle License Number
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