HomeMy WebLinkAboutSeptic Pumping Slip - 719 JOHNSON STREET 8/15/2018 Commonwealth of Massachusetts MCEIVED
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City/Town of .
" em i t�0
e � r
Fonn 4 TOWN Or NORTH ANDOVER
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 farm,check with your
local Board of Health to determine the form they use. The System Pumping Record must be submitted to 1
the local Board of Health or other approving authority.
A. Facloty, I nfor Mationr
1. System Location: Left J Plight front of Douse, Left J Right rear of house, Lett&ht sl a of house Left
Right side of building, Left I Right front of building, Left J bight rear of building, n er ec
. Address
C1tyfTown state Zip Code
2'. System Owner.
Name.
Address(if different from location)
Cityrrown Stat 1 ,d
Telephone Number ;
® Pumping Rpcord
1. Date of Pumping ._ -- 2. Quantity Pumped: Gallons
3. Type-of s
YR Y-stern: El
Cesspool(s) - Septic Tank Tight Tank
• t
[� Other(describe):
4. Effluent Tee Filter present? Yepo if yes, was 9t cleaned? Yes El No,
5. Condition of System: (� /
4VV
Q\.
6.• System Pumped BY..
Neil.Bates7on F5821
Name Vehicle t_lcense Number
Bateson Enterprises Ina
Company
7. Lorr^ ie contents-were disposed:
( Lowell Waste Water
Sign a Fl�ul Cate S
15tbrmCdoo•06/03 System Pumping Record a Page t of 1