HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 103 JOHNNY CAKE STREET 7/1/2020 Commonwealth of Massachusetts
RECEIVED
City/Town of JUL 01 2020
System Pumping Record TOWN OF NORTH ANDOVER
Form 4 HEALTH DEPARTMENT
DEP has provided this form for us&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 forrn 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 hous. , / 'g i e of house Left
Right side of building, Left/Right front of building, Left/Right rear of mg,
Address �.
Citylrown State Zip Code
2. System Owner.
Name'
Address(ff different from location)
CWrown Stat , A _Zip Q -
Telephone Number
6. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped:
Gallons
3. Type-of system: ❑ Cesspool(s) ptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes D_ If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System: "S� r�
6. System Pumped By- 0
Neil.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. LocatI re contents-were disposed:
L S Lowell Waste Water
SignlWe fHauleifDate
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