HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 858 JOHNSON STREET 9/7/2021 Commonwealth of Massachusetts RECEIVED
_ City/Town of SEP 0 7 2021
System Pumping Record TOWN OF NORTH ANDOVER
Form 4 HEALTH DEPARTMENT
DEP has provided this form for us&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 hoes Llngg,
/'Rig ear ouse Left/right side of house, Left 1
Right side of building, Left/Right front of bul Left/Right rear building, Under deck
Address
CWTown v State N �!-r Zip-Code L✓
2: System Owner.
Name
Address(if different from location)
City/Town State /��� � ,ip CndR�/ G
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 E,�o If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System: P� /r
C Lk
6. System Pumped By:
Neil.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc-
Company
7. Location where contents were disposed:
Lowell Waste Water
SignAtute qt HauleV Date
Iftrm4.doaw 06/03 System Pumping Record•Page 1 of 1