HomeMy WebLinkAboutSeptic Pumping Slip - 1187 SALEM STREET 10/16/2017Commonwealth of Massachusetts
City/Town of
System Pumping. Record
Form 4
ECE V
6 7011
TOWN OF NORTH ANDOVER
HEALTH DEPARTMENT
DEP has provided this form for useby 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 Righ front of house?Left/ Right rear of house, Left/ right side of house, Left /
c..1e0
Right side of building, Left / Right front of building, Left / Right rear of building, Under deck
Address
I ‹f=k\t' •
City/Town
2. System Owner:
Name'
Lj
,P)
State •Zip Code
Address (if different from location)
City/Town
State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping
3. Type -of system: 0
0 Other (describe):
Date
uantity Pumped:
Cesspool(s) LK Septic Tank 0 Tight Tank
4. Effluent Tee Filter present? Ej Ye I3 No
" 5. Condition of Systern:
6; System Pumped By:
Neil Bateson •
' Name
Bateson Enterprises Inc
Company
7. 17ocat1611Where contents were disposed:
S: Lowell Waste Water
•
If yes, was it cleaned? 0 Yes Ej No,
F5821
Vehicle License Number
CO —
Date
t5form4.doc• 06/03 System Pumping Record • Page 1 of 1