HomeMy WebLinkAboutMiscellaneous - 93 CRICKET LANE 4/30/2018 (4)�L\ Commonwealth of Massachuset RVC
City/Town of
System Pumping Record JUL -i'2 2012
~ Form 4 TOWN OF NORTH ANDOVER
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: e n of hou eft /Right re use, Left /right side of house, Left /
Right side of b 'I g, Left / Ig t front of building, Left /Right rear uilding, Under deck
Ad ss 93 ^ �h r
City/Town (� tate Zip Code
2. s m -Owner.
Name
Address (if different from location)
City/Town State � ` 5Zip e
17
Telephone Number
B. Pumping Record
1. Date of Pumping
3. Type of system: ❑
Other (describe):
Date 2. Quantity Pumped
Cesspool(s)erptic Tank 41--
4. Effluent Tee Filter present? ❑ Yes ❑ No
ition of System:
6. System Pumped By:
Neil Bateson
Name
Bateson Enterprises Inc
Company
7. Locati where contents were disposed:
G.L S. _ Lowell Waste Water
Gallons
❑ Tight Tank
If yes, was it cleaned? ❑ Yes ❑ No
F5821
Vehicle License Number
(J' --mss ` (r}
Date
t5form4.doc• 06/03 System Pumping Recons • Page 1 of 1
Commonwealth of Massachusetts
w City/Town of
System Pumping Record
Form 4
DEP has provided this form for use by local Boards of Health. Other fo s
information must be substantially the same as that provided here. Befo . , I.,h 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 eft front of , right front of house, left side of house, right side of house, Left
rear of house, ri r'of house, left side of building, right rear of building, under deck.
Cityfrown State
2. System Owner: �- s
Name
Address (if different from location)
City/Town
B. Pumping Record
1. Date of Pumping
3. Type of system: ❑
❑ Other (describe):
t- —10
— 2. Quantity Pumped
eptic Tank
Date
Cesspool(s)
Zip Code
State Zip Code
Telephone Number
Gallons
❑ Tight Tank
4. Effluent Tee Filter present? ❑ Yes o If yes, was it cleaned? ❑ Yes ❑ No
5. Conditionof System:
� j v� �� \ V�-
6. System Pumped By:
Neil J. Bateson
Name
Bateson Enterprises Inc.
Company
7.;.L.S.D.
cation re contents were disposed:
ell Was Wa
-
ler
F5821
Vehicle License Number
Date
P3-g-<Cv
t5form4.doc• 06/03 System Pumping Record • Page 1 of 1