HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 981 JOHNSON STREET 5/17/2021 RECEIVED
Commonwealth of Massachusetts
jN 7 2021
City/Town of
OF MopTH
System Pumping Record TOHEA130DEPARTMENT ANDovER
Form 4
DEP has provided this form for umby 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, Left/Right rear of house, Left/ ght side of hous Left
Right side of building, Left/Right front of building, Left/Right rear of building, deck
Address
City/Town State Zip Code
2. System Owner.
Name'
Address(if different from location)
CWrown st*"� an Code
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Type-of system: ❑ Cesspool(s) ptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
6. System Pumped By:
Neil.Batesbn F5821
Name Vehicle License Number
Bateson Enterprises Ina
Company
7. Lo a contents-were disposed:
G_ S / Lowell Waste Water
Sign a Haul Data
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