HomeMy WebLinkAboutMiscellaneous - 889 JOHNSON STREET 4/30/2018 (3)Q
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W° System Pumping Record f Ak 3 u z0>>
Form 4 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 Locatio < Left front of hous right front of house, left side of house, right side of house, Left
rear of house, right rear of house, left side of buildinq, right rear of buildinq, under deck.
City/Town
2. System Owner: khkP
Name
Address (if different from location)
City/Town
B. Pumping Record
1. Date of Pumping
3. Type of system: ❑
❑ Other (describe):
4AC4-'- 61Q—tl
State Zip Code
VA
State Zip Code
Telephone Number
3- 1��
Date 2. Quantity Pumped:
Gallons
Cesspool(s)0-S'eptic Tank ❑ Tight Tank
4. Effluent Tee Filter present? ❑ Yes 2'No If yes, was it cleaned? ❑ Yes ❑ No
5. Condi io 0Cyst JU��A
6. System Pumped By:
Neil J. Bateson
Name
Bateson Enterprises Inc.
Company
7. Lojatka&here contents were disposed:
G.L.S.
IF
F5821
Vehicle License Number
Date
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