HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 970 JOHNSON STREET 11/30/2020 ..� Commonwealth of Massachusetts RECEIVED
City/Town of NOV 3 0 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 beused, 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/Right rear of houses Left/right side of house, Left
Right side of building, Left/Right front of building, Left/Right rear of building, Under deck
Address / �C) l,'1l��ji:v .S 1 kc,
Cityrrown C• State Zip Code
2. System Owner.
Name
Address(if different from location)
City/Town Stat _ Zip Code
4N_ Telephone Number
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped:
Gallons
3. Type of system: ❑ Cesspool(s) Q Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes 0 No If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System: /
6. System Pumped By:
Neil Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Location wviere contents were disposed:
Lowell Waste Water
4Sign9tHaul Date
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