HomeMy WebLinkAboutSeptic Pumping Slip - 981 JOHNSON STREET 10/6/2010 Commonwealth of Massachusetts
City/Town of
System Pumping Record
Form 4 TOWN Orr NORTiI ANDOVER
HEAL714 DEFIARTMEN-r
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 tQ 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 side of house, Right side of house, Left front of hous Right font of house,)
Left rear of house, Right rear of house. Left rear of building. Right rear of
—----------------------
Address
Cityrrown State Zip Code
2. System Owner:
Name
------—------- a__.._,..__,.._..___
Address(if different from location)
City/Town State /I Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping U Date 2. Q ntity Pumped: ts
Gallons
3. Type of system: F1 Cesspool(s) ja Septic Tank ❑ Tight Tank
❑ Other(describe): ----------------
4. Effluent Tee Filter present? ❑ Yes 2, '--No If yes, was it cleaned? F-1 Yes ❑ No
5. Conditiorl of 0s�e TO-CA
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6, System Pumped By:
Neil Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. L atiro"ll re contents were disposed:
Lo
aste Water
9wey
Signature 0
ignature 01 Ha er Date
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