HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 693 JOHNSON STREET 6/9/2020 Commonwealth of Massachusetts RECEIVED
City/Town of JUN 0 9 2020
System Pumping Record
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 Location• e—1mg C'ga=�nt
of ousea Left/Right rear of house, Left/right side of house, Left 1
Right side of bui , Left/ oi' wilding, Left/Right rear of building, Under deck
Address / \j ( \
City/Town State Zip Code
2. System Owner.
Name
Address(if different from location)
CiWTown Stat Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Type of system: ❑ Cesspool(s) eptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? es E� If yes, was it cleaned? Yes ❑ No
5. Condition of System:
- a 4--� vke-<--- L/,/10
6. System Pumped By:
Neil Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc-
Company
7. Locati 4hherentents were disposed:
G L SLowell Waste Water
Sign a Date
t5form4.doc-06/03 System Pumping Record•Page 1 of 1