HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 506 SALEM STREET 12/16/2020 Commonwealth of Massachusetts
City/Town of RFrFiVED
System Pumping Record DEC 16 2020
Form 4
TOWN OF NORTH ANDOVER
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 LocatioRig nt of ou Left/Right rear of house, Left/right side of house, Left
Right side of b g, Left/ ro of building, Left/Right rear of building, Under deck
MyRo" State Zip Ca'e
2. System Owner.
Name"
Address(if dMerent from location)
CiWTowrr State Zip e
Telephone Number
B. Pumping Record
1. Date of Pumping gate 2 Qu umped: moons
3. Type-of system: ❑ Cesspool(s) ;-Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes o If yes, was 4t cleaned? ❑ Yes ❑ No
5. Condition of System:
6. System Pumped By:
Nett.Meson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Locati contents-were disposed:
ALLSQ Lowell Waste Water(4 K ra&A
1 —
Signitie f H"Mu Date
t5tamm4.doc-06103 System Pumping Record•Page 1 of 1