HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 805 JOHNSON STREET 9/19/2022 Commonwealth of Massach
usetts`JSetts RECEIVED
City/Town of
System PUMPIng Record SEP 192022
Form 4
TOWN OF NORTH ANDOVER
HEALTH DEP has provided this form for use by local Boards of Health. Other forms may be used,ENT
information must be substantially the same as that provided here. Before Usingthis f
local Board of Health to determine the form they use.The System Pumping but the
the local Board of Health or other approving y form, chectc with your
pp g authority. p 9 Record must be submitted to
A. Facility Information
Important.
When filling out 1• 'System Location:
forms on the
computer,use
only the tab key 7Addre-ss ---
to move yourcursor-do not /Vuse the return tY/Town n V eJ
key. State
2• System Owner: Zip Code
��
Name
rrtm '�f Address(if different From location
City/Town
State Zip Code
Telephone Number
�. �U����� �G�oOo®9'CI •
1. Date of Pumping -
Date - 2. Quantity Pumped:
3. Type of System: Gallons
❑ Cesspool(s) � Septic Tank El Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes ❑ No If yes, was it cleaned?
❑
5. Condition of System: a. ❑ YeS No
Ali' e � c S S
r7
6. System Pumped By:
Name
Vehicle License Number
Company �'CS Se IrC
7. Location where)J contents were disposed:
4A vcr
Signature of Hauler
Data '•
t5form4.doc-06/03
System Pumping Record Page 1 of i
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