HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 1510 SALEM STREET 5/26/2020 .A\, Commonwealth of Massachusetts RECEIVED
City/Town of MAY 2 6 2020
N.I F. System Pumping Record
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 to
the local Board of Health or other approving authority.
A. Facility Information
1. System Location: Left/Right front of tiouA�lnhgg,
gh �house�
Left/right side of house, Left
Right side of building, Left/Right front of b`uIl ft building, Under deck
Address � l C)
Citylrown State Zip Code
2. System Owner.
Name
Address(if different from location)
CitylTown State ` — p Code
7
Telephone Number
B. Pumping Record
1. Date of Pumping 2. Quantity Pumped:
Date Gallons
3. Type-of system: ❑ Cesspooi(s) eptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes L 7'No 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. ZS. 1
tents-were disposed:
Lowell Waste Water
IS1 Date
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