HomeMy WebLinkAboutSeptic Pumping Slip - 1020 SALEM STREET 11/7/2017 Commonwealth of Massachusetts
RECEIVED
v .. C4/Town of .
n.: Q
y�tem Pumping.Record C2011
Form 4 TOWN OF NORTH ANDOVER
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 too
the local Board of Health or other approving authority.
A. Facii%tY Informlation
1. System Location; Left I Right front of house, Left 1 Right rear of house, Left right side of housed Left/
Right side of building, Left/Right fr6nt of building, Left/Right rear cif building,q cn c
Address
City/Town w state Zip Code
2. System Owner.
Name'
Address(if different from location)
Cl /Town '
ty • State• Zip
Telephone Number
. Pumping Record �
1. Date of Pumping — 2. Quantity Pumped:
Gallons
3. Type-of system: ❑ Cesspool(s) eptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yep o If yes, was it cleaned? ❑ Yes ® No,
' 5. Condition of Syrstem:
6: System Pumped By:
Neil.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc'
Company
7. Lo�LS'
here contents were disposed:
Lowell Waste Water
Signitufa 9t HguleU Gate
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