HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 1514 SALEM STREET 7/1/2020 Commonwealth of Massachusetts RECEIVED
= City/Town of JUL 0 11020
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, Left/Right rear of house, Leftt_rlghi ide of itou!e, 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
Address(if different from location)
Cityrrown State ,ty Code
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Type of system: ❑ Cesspool(s) eptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes L7 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. Locati ere contents were disposed:
G L S. � Lowell Waste Water
Sign a Haul Date
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