HomeMy WebLinkAboutSeptic Pumping Slip - 144 GRANVILLE LANE 10/30/2017Commonwealth of Massachusetts
City/Town of
System Pumping_Record
Form 4
c
OC; 30 2017
TOWN OF NORTH ANDOVER
DEP has provided this form. for use.by local Boards Of Health. Other forms may be db('t7,TMENT
informallorrmust 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 hous ;, Left / right side of house, Left /
Right side of building, Left / Right front of building, Left / Right rear Of building, Under deck
Address
t LE Lf L Ak--t(4. (C-
City/Town
2. System Owner:
State
Zip Code
Name'
Address (if different from location)
City/Town
Stet 2Ip Code
Telephone Number
B. Pumping Record
(1c-
1. Date of Pumping Date 2. Quantity Pumped:
3. Typeof syttent
Other (describe):
4. Effluent Tee Filter present?
' 5. Condition of System:
'
Gallons
Cesspool(s) D Tight Tank
Yet EI-1‘) If yes, was it cleaned? 0 Yes 0 No,
6.- System Pumped By:
Neil Bateson
' Name
Bateson Enterprises Inc
Company
7. Loca ncontents were disposed:
Lowell Waste Water
F5821
Vehicle License Number
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