HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 991 JOHNSON STREET 7/1/2020 RECEIVED
.-C\- Commonwealth of Massachusetts JUL 01 2020
City/Town of
TOWN OF NORTH ANDOVER
System Pumping Record HEALTH DEPARTMENT
Form 4
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: Left/Right front of house, Left y ofha, Left/right side of house, Left 1
Right side of building, Left/Right front of building, Left/Right rear of building, Under deck
Address
Citylrown —�� State Zip Code
2. System Owner. , A
NII 'VAvt V/(
Name
Address(if different from location)
Cityrrown State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping 2. Quantity Pumped:
Date i Gallons
3. Type of system: ❑ Cesspool(s) E9
Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? EYes ❑ No If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
6. System Pumped By:
Neil.Bates-on F5821
Name Vehicle License Number
Bateson Enterprises Inc-
Company
7. Location where contents were disposed:
WSiignAtufe
Lowell Waste Water
G
ul Date
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