HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 767 JOHNSON STREET 6/2/2021 : Commonwealth of Massachusetts RECEIVED
City/Town of J0N 0 2 2021
° 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, Left/Right rear of hous-�;L eft/�`g 1 e of house Left 1
Right side of building, Left/Right front of building, Left/Right rear of�baii hg, Un
Address 7& ?
City/Town State Zip Code
2. System Owner.
Name'
Address(d different from location)
Citylrown State �1�s A '5�) Zi�Code
Tel one Number
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped:
Gallons
3. Type of system: ❑ Cesspool(s) ateptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System: NZ;ICOAI-�-
c4�C �.
6. System Pumped By:
Neil.Bates-on F5821
Name Vehicle License Number
BateSOn Enterprises Inc-
Company
7. Locatio where contentawere disposed:
�L S Lowell Waste Water
Signitute 9t Haul Date
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