HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 1592 SALEM STREET 9/25/2020 .&N- Commonwealth of Massachusetts RECEIVED
City/Town of SEP 2 5 202U
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 forrh they use. The System Pumping Record must be submitted to
the local Board of Health or other approving authority.
A. Facility Information
1. System LocatioiL�g fron ft/Right rear of house, Left/right side of house, Left,/
Right side of building, Left/Right front of building, Left/Right rear of building, Under deck
Address
Citylrom State Zip Code
2. System Owner.
Name.
Address(Ir different from location)
City/Town State
Telephone Number
6. Pumping Record
1. Date of Pumping Date 2 Quantity Pumped:
Gallons
3. Type-of system: ❑ Cesspool(s) M—Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes ET No If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of Syst
6. System Pumped By:
Neil.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Location where contents-were disposed:
GLLSQ Lowell Waste Water
LN riSA.
Sign We Haut Date
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