HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 437 SALEM STREET 11/30/2020 Commonwealth of Massachusetts RECEDE®
City/Town of
System Pumping Record Nov 3 0 Mu
Form 4 TOWN OF NORTH ANDOVER
HF4LTH DERARTh'ENT
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 housq j: gtcrear of house, Left/right side of house, Left
Right side of building, Left/Right front of building, Left/Rig —rear of building, Under deck
Address
—
CWTown state Zip Code
2. System Owner.
Name
Address(if different from location)
City/Town State Zp Code
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank
❑ Other(describe): /
4. Effluent Tee Filter present? ❑ Yes awo If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System: zlk �� -k-
6. System Pumped By:
Neil.Bateson _ F5821
Name Vehicle License Number
_Bateson Enterprises Inc
Company
7. Location where contents were disposed:
G L S-1p Lowell Waste Water
Sign a Haul Date
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