HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 1440 SALEM STREET 12/10/2019 Commonwealth of Massachusetts RECEIVED
City/Town of DEC 10 2019
System Pumping Record TOWN OF NORTH ANDOVER
Form 4 HEALTH DEPARTMENT
DEP has provided this form for use:by focal 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, Le r�gof
, Left/right side of house, Left
Right side of building, Left/Right front of building, Left/Rbuilding, Under deck
Address
city/Town State Zip Code
2. System Owner.
Name
Address(if different from location)
CWrown State- Zip
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped:
Gallons
3. Type of system: ❑ Cesspool(s) M_B p'c Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? es ❑ No If yes,was it cleaned? Q-Y6_❑ No
5. Condition of System-
6. System Pumped By:
Neil.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Ina
Company
7. Locatio ere contents-were disposed:
S Lowell Waste Water
GC
Sign We cfHaulerUDate
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