HomeMy WebLinkAboutSeptic Pumping Slip - 991 JOHNSON STREET 10/30/2017Commonwealth of Massachusetts
City/Town of.
System Pumping Record
Form 4
CE1V
D
3 0 2017
TOWN OF NORTH ANDOVER
T DEFARTbAENT
DEP has provided this form for use local Boards of Health. Other forms may Mslea, cut the
information must be substantially the same as that provided here. Before using.this forrn, 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/ f housel) Left / right side of house, Left /
Right side of building, Left / Right front of buildirig, Left / Right rear Of building, Under deck
Address /Th, /-\ .
City/Town State
2. System Owner:
Zip Code
Name.
Address (if differentfrom location)
City/Town
•
Telephone Number
B. Ptimping R!cord
1 i
1. Date of Pumping
Date 2. Quantity Pumped: Gallons
3. Typeof system: D Cesspool(s) eptic Tank E:1 Tight Tank
0 Other (describe):
4. Effluent Tee Filter present? No If yes, was it cleaned? [9—ye-§-0- No,
Condition of Syste :
6. SysteM Pumped By: I
Neil Batesbn,
• Name
Bateson Enterprises Inc
Company
7. Locatio Where contents were disposed:
aLowell Waste W
VAL)k (A-
F5821
Vehicle License Number
t5form4.doc• 06/03
System Pumping Record • Page 1 of 1