HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 518 SALEM STREET 5/18/2020 : Commonwealth of Massachusetts =JECENED
MEMEMEMMS
City/Town of MAY 18 2020
System Pumping Record TOWN OF NORTH ANDOVER
Form 4 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 to
the local Board of Health or other approving authority.
A. Facility Information
1. System Location: Left/Right front of house,<�g ear of house, Left/right side of house, Left
Right side of building, Left i Right front of building, Left/Right rear of building, Under deck
Address
City/Town State Zip Code
2. System Owner.
Name'
Address(if different from location)
cityrrown state� 3 4 r,D code
Telephone Number ti
B. Pumping Record
1. Date of Pumping Dam ;�eptic
Quanti Pumped:
Gallons
3. Type of system: ❑ Cesspool(s) Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes Ea o If yes,was it cleaned? ❑ Yes ❑ No
5. Condition of System:
6. System Pumped By:
Neil.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Location where contenttr were disposed:
�L S Lowell Waste Water
Sign aqt Haut Date
t5fomn4.doa 06/03 System Pumping Record•Page 1 of 1