HomeMy WebLinkAbout- Septic Pumping Slip - 30 SUMMER STREET 10/19/2018 (3) Commonwealth of Massachusetts RECEIVED
City/Town of oc"I 19 2018
Pumping Record 'TOWN OF NORTH ANDOVER
System
Form 4 HEALTH DEPARTMENT
DEP has provided this form for use-by local Boards of Health. Other forms maybe'used,but the
information-must be substintially the tame as that provided here. Before using.this form,check with your
local Board of Health to determine the forrh they use.The System Pumping Record must be submitted to
the local Board of Health or other approving authority.
A. Facift Inform' ation
1. System Locatto !RIaLft"f4prit of Flow, Left/Hight rear of house, Left.I right side of house, Left I lt
Right side of bui O' L ag.,OL aft I RIg-W red of building, Left/Right rear of building, Under deck
Address
city/Town state Zip Code
2. System Owner.
Adddifferent from location)
Cityfrown state Zip Code
Telephone Number
.B. Pumping Record
1. Date of Pumping Date -��:2, Q ept�u7nfity Pumped: Gallons
3. Type-of system: El Cesspool(s) o T nk D Tight Tank
[J Other(describe): 1,
4. Effluent Tee Filter present? Yes Q'i�0 if yes, was it cleaned? Yes No
5. Condition of System:
6. System Pumped By:
Nell,Bates7on F5821
Name Vehicle License Number
Bateson Enterprises Incr
Company
7. LocaOtiqmAw re contents.were disposed:
4G,LSJ? Lowell Waste Water
SIgne ' Hliul' Date
tftrm4.doo-08/03 System Pumping Record Page 9 of 9