HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 1794 SALEM STREET 8/24/2020 Commonwealth of Massachusetts RECEIVED
City/Town of
IF System Pumping Record '�� 2 1_a20
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
informations 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 Locatio t front o house`dLeft/Right rear of house, Left/right side of house, Left
Right side of building, Left/Right ron o uildirig, Left/Right rear of building, Under deck
Address
Citylrown State Zip Code
2. System Owner.
Name' J
Address(if different from location)
CitylTown State Zip Code
Telephone Number
B. Pumping record
1. Date of Pumping Elate 2. Quantity Pumped:
Gallons
3. Type-of system: ❑ Cesspool(s) eptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes 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. Lo here contents-were disposed:
XLowell Waste Water
t C 7
SignAWe fHaulwUData
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