HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 767 JOHNSON STREET 7/2/2020 Commonwealth of Massachusetts RECEIVED
City/Town of
System Pumping Record JUL 0 1 201i3
Form 4 TOWN OF NORTH ANDOVER
�• HEALTH DEPARTMENT
DEP has provided this form for use=by local Boards of Health. Other forms may beused, 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/Right rear of house, oef`/,right side of house, Left 1
Righ"ide of building, Left/Right front of building, Left/Right rear of building, Under deck
Ad ess
City/Town State Zip Code
2: Syst�m Owner
Name _--
Address(if different from location)
Cityrrown State v� Zip Code
S2�c
Telephone Number
B. Pumping Record
1. Date of Pumping Date 1 v 2. Quantity Pumped: Gallons
3. Type of system: ❑ Cesspool(s) Q Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes ❑ No If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
6. System Pumped By:
Neil.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc-
Company
7. Location where contents-were disposed:
Lowell Waste Water
Sign aIt Haul Date
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