HomeMy WebLinkAboutSeptic Pumping Slip - 50 TURTLE LANE 10/30/2017O2(7
1. Date of Pumping
Commonwealth of Massachusetts
City/Town of . • •
System Pumping. Record
Form 4
ECEIV
MI 30 ?OH/
TOWN OFNORTH ANDOVER
HEALTH DEPARTMENT
•
DEP has provided this forrn. for usetq local Boards Of Health. Other forms may be 'used, but the
information' must be substantially the same as that provided here. Before using.this forrn, 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 t ,fronlpfoute.,-Left/ Right rear of house, Left / right side of house, Left /
Right side of building, LeTTight front of building, Left / Right rear of building, Under deck
Address So TCi-
City/Town
2. System Owner:
State
Zip Code
Address (if different from lo
tion)
City/Town '
Telephone Number
B. Pumping Record
Date
3. Typeof system": El Cesspool(s) lc Tank El Tight Tank
El Other (describe):
4. Effluent Tee Filter present? 0 Yes If yes, was it cleaned? EJ Yes El No,
5. Condition of System:
6: System Pumped By:
Neil Bateson
' Name
Bateson Enterprises Inc
Company
7. Location where contents were disposed:
Lowell Waste Water
2. Quantity Pumped:
F5821
Gallons
Vehicle License Number
t5form4.doc. 06/03 System Pumping Record • Page 1 of 1