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Commonwealth of Massachusetts
City/Town of OCT 2 1013
System Pumping Record TOWN OF NORTH ANDOVER
Form 4 L HEALTH DEPARTMENT
DEP has provided this form for use: by local Boards of Health. Other forms may be used, but the
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 house,/tVeRight:ngg�, Left/ right side of house, Left/
Right side of building, Left / Right front of buMffing, Left / Right rear of building, Under deck
Address P
Cityrrown state
2. System Owner
Name
Address (if diftrent from location)
City/Town
B. Pumping Record
1. Date of Pumping
3. Type of system*-.
Zip Code
lZin Carle
Telephone Number
2. Quantity Pumped:
Date Galions
Cesspool(s) 0-tieptic Tank El Tight Tank
El Other (describe):
4. Effluent Tee Filter present? F1 Ye.,s a--N�o
If yes, was it cleaned? [] Yes E] No
5. CondiNon,of System-
(Ie� �
6. System Pumped By.
Nell Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. L re contents were disposed:
nZ
rGL L, S. Lowell Waste Water
P-17- t3
uleq I Date
t5form4.doc- 06/03 System Pumping Record - Page I of 1
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Commonwealth of Massachusetts
City/Town of
System Pumping Record
Form 4
IV E C
SEP 14 2007
I TO'�AIN OF NORT9 ANDOVER
F,F,�,, i. i� IQG
DEP has provided this form for use by local Boards of Health. Other iorms may 6�'u &thd
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:
Cityrrown
2. System Owner
Name
Address (if different from location)
Cityrrown
0_C
0
Zip Code
state,,,, Zip Code
(Z)
Telephone Number
B. Pumping Record
1 . Date of Pumping Date 2. Quantity Pumped: Gallons
3. Type of system: El Cesspool(s) E3-SU-pffic Tank [7 Tight Tank
El Other (describe):
4. Effluent Tee Filter present? El Yes If yes, was it cleaned? E] Yes n No
5. Conditi n System:
M� U�-�
6. Syste P ped Ely"
Name
Company
7. Location "re contents were
Vehicle License Number
Date
-t
t5form4.doc- 06/03 System Pumping Record - Page 1 of 1
OF NORTH'AUDO
VER'
:"SYSTEM PUM,pl
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,.,V�.TEM QWNFR ADDRESS
r
IV- 4�
SYSTEM L6-C—;-A—TI0N---
front of hou�t)
,/34-6K
QUANTITY PUMPQ- D Avd(
C"A L L
s 1, o o L: N 0
SEPTIC T ANK: NO.— YES
N.ATURE OF SERVI.M"ROUTINE.
EMERCEN'CY
I j r R YA T 10 N S.,-.
FULL70 COYC- k.
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CXCESSI.YE% SOLIDS**:
FLOO-DW
"'C R Y�0,y
L, Im c b
I 'PUMP 0 Y:'
"I -,y I r�, N T S:
RU, D T01,
Commonwealth of Massachusetts
Cityfrown of
System Pumping Record
Form 4 FOCT 3 C Lu;u9
DEP has provided this form for use by local Boards of ealth. Other for a used, but the
a
t0h ri
'c
y
'y
OF J
r a - ng thi form, check with your
information must be, substantially the same as that pro'bM -% je�#,
local Board of Health tQ determine the form they use. ihe-9j-'s1e6"-PGr"Wing ecord must be submitted to
the local Board of Health motft6r approving authority.
A. Facility Information
1. System-LoGatiQn: Left side of house, Right side of house, Left front of house, Right front of house,
Right rear of house. Left rear of building. Right rear of building.
Address
D`7
Cityrrown State Zip Code
2. System Owner:
Name
Address (if different from location)
City/Town
B. Pumping Record
1. Date of Pumping
3. Type of system: El
El Other (describe):
State Z' C de
Telephone Number
Quantity Pumped:
Date Gaillons
Cesspool(s) e—Septic Tank El Tight Tank
4. Effluent Tee Filter present? [j Yes If yes, was it cleaned? E] Yes 0 No
5. Condition of System:
6. System Pumped By:
Neil Bateson
Name
Bateson Enterprises Inc
Company
7. Location where contents were disposed.-
G.L. D Lowell Waste Water
Signature of Hauler
F5821
Vehicle License Number
�0 1) (-(:D�
Date
t5form4.doc- 06/03 System Pumping Record - Page 1 of 1
Commonwealth of Massachusetts
COVED
City/Town of FR
System Pumping Record 1
Form 4
T Tnw
OWN OF NORTH ANDOVER
NORTH _�92�ER
DEP has provided this form for use by local Boards of Health. Other g rrrsan i .
information must be substantially the same as that provided here. Be re 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 Locatio * ht front of hous<1L-e-'V" RigKJLea� -of �hous eft / right side of house, Left I
Right side of buVii Veft'gj/ Right front of building, Left / Right rear of building, Under deck
Address �D- V-�
Cityrrown
2. System Owner:
Name
Address (if different from location)
Cityfrown
B. Pumping Record
1. Date of Pumping
3. Type of system: F�
C)
State
Zip Code
State Zip Code
Telephone Number
to -'�!) (b — k k
Date 2. Quantity Pumped:
Cesspool(s) Er'S—eptic Tank
El Other (describe):
4. Effluent Tee Filter present? E] Yes a -'No
5. Condition of System:
6. System Pumped By:
Neil Bateson
Name
Bateson Enterprises Inc
Company
Gallons
El Tight Tank
If yes, was it cleaned? E] Yes El No
(-Q�LeA 11\ (I\.- -4���
7. Locati hei� contents were disposed:
G.LS.W- Lowell Waste Water
F5821
Vehicle License Number
I
Date
t5form4.doc- 06/03 System Pumping Record - Page I of 1