HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 940 JOHNSON STREET 7/1/2020 Commonwealth of Massachusetts RECEIVED
City/Town of JUL 0 12020
System Pumping Record TOWN OF NORTH ANDOVER
Form 4 HEALTH DEPARTMENT
DEP has provided this form for use-by local Boards of Health. Other forms may 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: Left/Right front of house, Left/FtLqtpear of hour Left/right side of house, Left
Right side of building, Left/Right front of building, Left fight rear of building, Under deck
,dress q. _C o
cityrrown State Zip Code
2. System Owner.
Name'
Address(if different from location)
CitylTawn State�g —are ( Zip-"@
Telephone Number
B. Pumping record
1. Date of Pumping Date 2. Quantity Pumped:
Gallons
3. Type-of system: ❑ Cesspool(s) is Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? aNs ❑ No If yes, was it cleaned? ❑—Yew❑ No
5. Condition of System: � �7A
VN,UTVVVCLt
6. System Pumped By-
Neil.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Ina
Company
7. Location where contents-were disposed:
G�.SQ __ Lowell Waste Water
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Sign acfHbuWUDate
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