HomeMy WebLinkAboutSeptic Pumping Slip - 56 CRICKET LANE 4/12/2012 I
Commonwealth of Massachusetts
RECIEWED
ED
=A City/Town of
System Pumping Record 2 4 Z Ol
J` Form 4
r�w� i of NORTH ANDOVER
till f '.rA TM
DEP has provided this form for use by local Boards of Health. G eased, ut 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, Left Rig tfi rear of hw , Left J right side of house, Left J
Right side of building, Left/Ri ht front of building, Left/Right rear of building, Under deck
54 C(- k
Address
City/Town State Zip Code
2. System Owner:
Name
Address(if different from location)
Cityrrown State Zip Code
to
Telephone Number
B. Pumping Record
1. Date of Pumping _ 2. Quantity Pumped:
Date Gallons
3. Type of system: ❑ Cesspool(s) Ey/Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes Q No If yes,was it cleaned? ❑ Yes ❑ No
5. Condition of System: j
6. System Pumped By:
Neil Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Locatic►mwhere contents were disposed:
G1,S. Lowell Waste Water
Sign toe Haule Date , l 0, _ t�
t5form4.doc•06/03 System Pumping Record•Page 1 of 1