HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 850 JOHNSON STREET 8/24/2020 Commonwealth of Massachusetts RECEIVED
City/Town of
System Pumping Record AUG 2 4 2020
Form 4 TOWN OF NORTH ANDOVER
HEALTH DEPARTMENT
DEP has provided this form for use-by local Boards of Health. Other forms maybe 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/ ght ear of hous , Left/right side of house, Left
Right side of building, Left/Right front of building, a I Right rear of building, Under deck
Address g_CS O
City/Town State Zip Code
2. System Owner. 1
Name y
Address(ir different from location)
cWrown State' Tip Code
-t—�.5t v
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? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System: c..-
6. System Pumped By:
Neil.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Lo ere contents-were disposed:
Q L S. J Lowell Waste Water
Sign a Haul Date
t5fomv4.doe-06/03 System Pumping Record•Page 1 of 1