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Commonwealth of MassachusettsIv�
f City/Town of
W° System Pumping Record
T®1NN10P NORTH ANDOVER
Form 4 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 Locatierefot e, right front of house, left side of house, right side of house, Left
rear of h se, right rear of house. Is t side of building. riaht rear of huildinn unciPr dirk
-----------------
qo
City/Town
2. System Owner: �1
Address (if different from location)
City/Town
B. Pumping Record
1. Date of Pumping
3. Type of system: ❑
❑ Other (describe):
State Zip Code
state i de
Telephone Number
- to /
Date 2. Quantity Pumped: Gallons
Cesspool(s) Septic Tank ❑ Tight Tank
4. Effluent Tee Filter present? ❑ Yes If yes, was it cleaned? ❑ Yes ❑ No
5. Con tion of System-
( I oc'�-.
6. System Pumped By:
Neil J. Bateson
Name
Bateson Enterprises Inc.
Company
7. Lo�here contents were disposed:
F5821
Vehicle License Number
Date
'3—/o
t5form4.doc• 06/03 System Pumping Record • Page 1 of 1