HomeMy WebLinkAboutSeptic Pumping Slip - 1070 SALEM STREET 6/29/2017Commonwealth of Massachusetts
City/Town of
System Pumping. Record
Form 4
ECEIVED
Jot, c) 5 2U1(
rOWH OF RTH ANDOVER
PARTMENT
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 ystem 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 hous
Right side of building, Left / Right front of building, Left / Right rear of
Address I 0,7 • tue2a,*
City/Town State
2. System Owner
c
sid of hous, Left /
lrng, Undfdec
Zip Code
Name.
Address (if different from location)
City/Town
Telephone Number
B. Pumping Record
1. Date of Pumping
Date
29ntity Pumped:
Gallons
3. Type.of system 0 Cesspool(s) Septic Tank 0 Tight Tank
0 Other (describe):
4. Effluent Tee Filter present? Ej Yep D'‘) If yes, was it cleaned? 11 Yes El No,
' 5. Condition of Sys
6. System Pumped By:
Neil. Bateson
Name
Bateson Enterprises Inc
Company
7. Locatio .30 e contents were disposed:
GL S. Lowell Waste Water
F5821
Vehicle License Number
t5form4.doc• 06/03 System Pumping Record • Page 1 of 1