HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 50 JOHNNY CAKE STREET 9/21/2020 Commonwealth of Massachusetts RECEIVED
_ City/Town of SEP 21 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 front of house, e /ig rear of house,Left/right side of house, Left
Right side of building, Left/Right front of bulling, Left/Right rear of building, Under deck
Address C� C�V�V\�� c cA
City/Town State Zip Code
2: System Owner. rA
C2 C
Name
Address(if different from location)
Cityffown state Zip Code
3c�
Telephone Number
B. Pumping Record
1. Date of Pumping 2. Quantity Pumped:
Date Gallons
3. Type of system: ❑ Cesspool(s) eptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? Q'Yes ❑ No If yes, was it cleaned? es ❑ No
5. Condition of System:
6. System Pumped By:
Neil.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc-
Company
7. Location re contents-were disposed:
G L S� Lowell Waste Water
ASignjWfe I -g
Haul Date
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