HomeMy WebLinkAboutSeptic Pumping Slip - 53 CEDAR LANE 10/30/2017Commonwealth of Massachusetts
City/Town of
111
/011
System Pumping -Record
Form 4
TOWN OF NORTH ANDOVER
HEALTH DEP has provided this form for use.by local Boards Of Health. Other forms may be Used, but the DFPARTMENT
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 house4
Right side of building, Left / Right frOnt of building, Le
Address
Ctty/Town
2. System Owner:
f hous‘, Left/ right side of house, Left /
/ Right rear Of building, Under deck
State
Name
Address (if different from location)
City/Town '
Stat
Telephone Number
B. Pumping Record
LP!:
1. Date of Pumping Date 2. Quantity Pumped:
3. Typeof system 0 Cesspool(s) D Septic Tank D Tight Tank
Gallons
Other (describe):
4. Effluent Tee Filter present?
' 5. Condition of System:
kJ
Yes No If yes, was it cleaned? D Yes El No,
6: System Pumped By:
Neil Bateson
' Name
Bateson Enterprises Inc
Company
7. Location Where contents were disposed:
al_ S. Lowell Waste Water
Sign t
F5821
Vehicle License Number
Date
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