HomeMy WebLinkAboutSeptic Pumping Slip - 1276 SALEM STREET 10/30/2017Commonwealth of Massachusetts
City/Town of
System Pumping Record
Form 4
001 3 0 201/
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 font' they use. The ystern Pumping Record must be submitted to
the local Board of Health or other approving authority.
A. Facility Information
1. System Location: Left / Right froilt of house,fe-0- Righq611 ouse eft/ right side of house, Left /
Right side of building, Left / Right front of bur diiig, Left / RightTeiFf- e building, Under deck
Address
jki A-1-40 0-6(
City/Town State
2. System Owner:
(\\1
Name'
Zip Code
Address (if different from location)
City/Town •
State
Zip Code
- (0, - S-19
Telephone Number
••
B. Pumping Record
1. Date of Pumping
Date
Lb'
uantity Pumped:
Gallons
3. Typeof system D Cesspool(s) Septic Tank LJ Tight Tank
El Other (describe):
4. Effluent Tee Filter present? Q Yes
" 5. Condition of Bysterry
System Pumped By:
Neil Bateson
Name
Bateson Enterprises Inc
Company
7. Locationhere contents were disposed:
Lowell Waste Water
Sign Hbule
If yes, was it cleaned? 0 Yes El No,
F5821
Vehicle License Number
Date
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