HomeMy WebLinkAboutSeptic Pumping Slip - 150 JOHNNY CAKE STREET 9/26/2017Commonwealth of Massachusetts
City/Town of.
System Pumping. Record
Form 4
ECEIV •
SFt 26 2011
TOWN OF NORTH ANDOVER
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 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 house, Left Ti nt rear of hous?Left/ right side of house, Left /
Right side of building, Left / Right front of building, e / Right rear of building, Under deck
Address
(ri
City/Town
2. System Owner:
State
Zip Code
Address (if different from location)
City/Town
State -
Zip Code
4.4
Telephone Number e
1
B. Pumping Record
1. Date of Pumping
3. Type•of system D Cesspool(s) 1J Septic Tank El Tight Tank
Other (describe):
4. Effluent Tee Filter present? Ye.s Ej No If yes, was it cleaned? Yes Ej No.
•
' 5. Condition of System:
d.,c)
Date
Quantity Pumped:
Gallons
6: System Pumped By:
Neil. Bates -on • F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Locatpn iNhere, contents were disposed:
Lowell Waste Water
Date
(7
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