HomeMy WebLinkAboutseptic tank - Septic Pumping Slip - 459 SALEM STREET 5/18/2020 .Y&\- Commonwealth of Massachusetts LFi!!l=®
City/Town of
System Pumping Record MAY 18 2020
Form 4 TOWN OF NORTH ANDOVER
RTtV C_:T
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 Locatiok lam/Right n hou 'Left/Right rear of house, Left/right side of house, Left
Right side of building, Left/Right front of building, Left/Right rear of building, Under deck
Address
City/Town State Zip Code
2. System Owner.
Name W
Address(if different from location)
Cityf town State• Zip Code
Telephone Number
B. Pumping Record /
1. Date of Pumping Date 2. Quantity Pumped:
Gallons
3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? es ❑ No If yes, was it cleaned? es ❑ No
5. Condition of System:
6. System Pumped By:
Neil.Batesbn F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Location where contents were disposed:
G L S Lowell Waste Water
Sign aflftuhmuDate
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