HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 2005 SALEM STREET 8/10/2020 : Commonwealth of Massachusetts RECEIVED
City/Town of AUG 10 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 used, but the
information-must be substandafly the same as that provided here. Before using.this form,check with your
local Board of Health to determine the forrim 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..e 2i f �' of
, Left/Right rear of house, Left/right side of house, Left
Right side of building, Left ilding, Left/Right rear of building, Under deck
Address �
Chty/Town State Zip Code
2. System Owner.
Name.
Address(if different from location)
CityfTawn St at"? 7 , , V Zip �Q�
Telephone Number
.B. Pumping record
1. Date of Pumping Date 2. Quantity Pumped:
Capons
3. Type of system: ❑ Cesspool(s) eptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? a Y D No If yes, was it cleaned? ❑t_Y No
5. Cond t' n of System: G`0��
6. System Pumped By.,
Neil.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Lol ati a contents-were disposed:
.L80 Lowell Waste Water
--�G a�
Sign a qt Haul Date
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