HomeMy WebLinkAboutMiscellaneous - Exception (769)Commonwealth of Massachusetts
City/Town of
System Pumping Record AUG 0 4 2014
Form 4 TOWN OF NORTH ANDOVER t
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: Left/ Right front of house, Left/ Right rear of house, Left-/ right side of house, Left/
Right side of building, Left / Right front of building, Left / Right rear of building, Under deck
Address
City/Town State Zip Code
2. System Owner.
Name
Address (if different from location)
Cky/rown ' State
Telephone Number `<
1
B. Pumping Record
1. Date of Pumping gate 2. Quantity Pumped: Gallons >—
3. Type of system. ❑ Cesspool(s) eptic Tank ❑ Tight Tank
❑ Other (describe):
4. Effluent Tee Filter present? ❑ Yes Q -No if yes, was it cleaned? ❑ Yes ❑ No:
'5. Condition of System:
(V6�� V\_A�� . t,
6. System Pumped By.-
Neil
y:
Neil Bateson
Name
Bateson Enterprises Inc
Company
7. LTLL72–
re contents were disposed:
Lowell Waste Water
F5821
Vehicle License Number
`7 --3> -1
Data
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