HomeMy WebLinkAboutSeptic Pumping Slip - 11 TANGLEWOOD LANE 8/15/2018 City/Town of .
ord R3 15 Z018
Form 4 'T'OWN OF NORTH ANDOVER
HEALTH DEFIARTMENT
DEP has provided this forrri for us&by local Boards of Health. Other forms may be'used,but the f
1
information•must be substantially the tame as that provided here. Before using.this farm,check with your J
local Board of Health to determine the forrh they use. The System pumping Record must be submitted to
the local ward of Health or other approving authority.
A. Fact ty. Information
1. System location: Left/Rightfront of!louse, Leat lht rear of hausLeft l righ#side of house, left/
Right side of building, Left/Right front of building, Left/ r
Righ ear of building, Under deck
Address _
City/f"own State Zip Code 1
2. System Owner
Name.
Address Of different from location)
Cityfrown ' state L Zip Code ;
'telephone Number e`er
t
13.
r
e
Pqmping Keeordf
9. bate of Pumping nate 2. Quantity Pumped: Gallons
3. Type-of systerA.- ❑ Cesspool(s) ir.Tenk ❑ Tight Tank
® Other(describe):
t
4.. Effluent Tee Filter present? ® Yes 0-1 o If yes, was itcleaned? ® Yes ❑ Na
' 5. Condition of system.
6. System Pumped By:
Feil.Meson n • F5821
Name Vehicle License Number
Bateson Enterprises Inc'
Company
7.JG-
contents,were disposed:
7- Lowell Waste Water
hlaule Gate
lftrm4.doc.•06103 system Pumping Record•Wage 1 of 7