HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 889 JOHNSON STREET 7/13/2020 RECEIVED
: Commonwealth of Massachusetts
City/Town of JUL 13 2020
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 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 nt of hous , Left fight rear of house, Left./right side of house, Left/
Right side of building, Left/Right front of b 'i Ing, Left/Right rear of building, Under deck
Address
Cityrrown State Zip Code
2. System Owner.
Name
Address(if different from location)
CityfTown 9�oe
Telephone Number
B. Pumping record
1. Date of Pumping Date ;�epbuc
Q ntity Pumped:
Gallons
3. Type of system: ❑ Cesspool(s) Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes 0 No If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System: fl�S vl. OtA „ p eA
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
LWaA.
Sign a gf-HaulerU Date
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