HomeMy WebLinkAboutSeptic Pumping Slip - 230 JOHNSON STREET 10/25/2017 Commonwealth of Massachusetts
RECEIVED
V M
QWTown of .
System Pumping.Record 0C 5 2 Oil
F®rrn 4 &N OF NORTH ANDOVER
HEALTH DEPARTMENT
®EP has provided this forrri for use-by local Boards of Health. Other form's maybe 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. FactIity. Inform' ation
1. System Location: Left/Right front of house, LeftfjCghtrear of hLeft/righ#side of house, Left/
Righ#side of building, Leff/RigfSt front of buildingRig`�`if rear of building, Under deck
Address .
City/rown cam' State Zip Code
2. System Owner:
Name'
f
Address(if different from location)
City/Town ' State- Zip Cad
"telephone Number
3 f .
P'umplingl Rpcord a'. (fi +�^ g
(. . 1 L / caeca'^, , ✓`1
1. Date of Pumping — 2. Quantity Pumped: Caftans caw j
3. Type-of system: ® Cesspool(s) ® Se tic Tan ❑ Tight Tank
Other(describe): 1
4.. Effluent Tee Filter present? ❑ Yes ® No if yes, was it cleaned? ❑ Yes ❑ No,
5. Condition of Sys k " a
6. System Pumped By:
Nell.Bates-on F5821
Name Vehicle License Number
Bateson Enterprises Ina
Company
?. Location where contents-were disposed: �
LS. Lowell Waste Water
Sign a Haule Date E
5form4.doc+06/03 System Pumping Record d Page 1 of 1
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