HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 901 JOHNSON STREET 7/13/2020 Commonwealth of Massachusetts RECEIVED
_ w City/Town of
M° System Pumping Record JUL. 13 2020
Form 4 TOWN OF NORTH ANDOVER
�•w 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: Left/Q front of hour, Left/Right rear of house, Left/right side of house, Left
Right side of building, Left/Right front of building, Left/Right rear of building, Under deck
Address Ctc
f
CWTown State Zip Code
2. System Owner.
Name
Address(if different from location)
Cityffown Stated � � 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 ❑ No If yes, was it cleaned? [g—YdS-0 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:
G L S Lowell Waste Water
��A-
Signitule 9t Haut Date
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