HomeMy WebLinkAboutSeptic Pumping Slip - 119 LIBERTY STREET 10/30/2017Commonwealth of Massachusetts
City/Town of
System Pumping Record
Form 4
ECEIVE
3 ? fl 1
TOWN OF NORTH ANDOVER
HEALTH DEPARTMENT
DEP has provided this form. for useby 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 qZ-iiarear of hOiiik Left / right side of house, Left /
Right side of building, Left / front of buildirig, eft Right rear of building, Under deck
Address
ii L
City/Town
2. System Owner:
J\J jt-I''‘OLO
State
Zip Code
Address (if different from location)
City/Town
i
State
Telephone Number
Zip Code
B. Pumping Record
016' 7
1. Date of Pumping Date0 2 uantity Pumped:
3. Typeof system 0 Cesspool(s) Septic Tank Ei Tight Tank
0 Other (describe):
4. Effluent Tee Filter present? E7Yes 0 No If yes, was it cleaned? IB<Yes 0 No,
' 5. Condition of System:
6. System Pumped By:
Neil Batesbn •
' Name
Bateson Enterprises Inc
Company
7. Lo on whir contents were disposed:
S. Lowell Waste Water
Sign Haul
F5821
Vehicle License Number
t5form4.doc• 06/03 System Pumping Record • Page 1 of 1