HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 507 SALEM STREET 9/21/2020 :_C\_ Commonwealth of Massachusetts RECEIVED
City/Town of SEP 212020
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 Ahis 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 tji ront o se, Left J Right rear of house, Left/right side of house, Left 1
Right side of building, Left/Right front of building, Left/Right rear of building, Under deck
Address �)V t
Cityfrown State Zip Code
2. System Owner.
Name
Address(if different from location)
CitylTown State►n t� G<�D
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? es ❑ No If yes, was it cleaned? ❑—Y6s_0 No
5. Condition � ste`A � / � _ ,G. � -12
6. System Pumped By:
Neil.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Location where contents were disposed:
Lowell Waste Water
4S&gnjtkujej_HQa�ut1 Date
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