HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 707 JOHNSON STREET 7/19/2021 : Commonwealth of Massachusetts
MEMOMMM
City/Town of RECEIVED
System Pumping Record 3UL 19 ZO
Form 4
TOWN OF NORTH ANDCvER
�LTH 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 forrh 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/right side of house, Left,/
Right side of building, Left/Right front of building, Left/Right rear of building, Under deck
Address ��u� t
City/Town State Zip Code
2. System Owner.
Name*
Address(ir different from location)
GityrTown Stater zill Code
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 D-*O If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
��" U l "fit✓ �/L��^�(/'�--
6. System Pumped By:
Neil.Batesbn F5821
Name Vehicle License Number
Bateson Enterprises Ina
Company
7. Locati ere ntente were disposed:
AG,LS-P Lowell Waste Water
Q_�A- 6�����
Sign We qt Haul Data
151ormCdoc-OW03 System Pumping Reeord•Page 1 of 1