HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 755 JOHNSON STREET 5/28/2024 yT� Commonwealth o* Massac.:
r City/Town of NORTH ANDOVER. MX,` SACHUSE:TT1%zj
4� A. ,- systems Pumping Record
DE' has provided this form for use by local Boards of Heai h. The System Pumping Record must
kze su:xni-tted to the local 3oard of Health or other approving authority.
F C€'ity information
Important:
When filling out 1. System Location:
forms on the '— [
computer,use , 5 O ,1 N s o/,/ S T
only the tab key Address
to move your /v�o f e-�
cursor-do not City(Tovrt ---.-- -- -- - State- — - -- Zip Code
use the return
key.
2. System Owner:
^
Name
j — ------ -'�--
" Address(d different from location) +` `L
Cityr7own State `�tA� _IpCode� - —
a _
Telephone Number r. -_-- -_-
B. Pumping Record
1- Date of Pumping Date �— 2- Quantity Pumped Gauons
3. Type of system: ❑ Cesspool(s) [?T<-eptic Tank [ Tight Tank
❑ Other(describe): -� -- --- - --- - ----------
4. Effluent Tee filter present? .❑ Yes l'I No if yes,was it cleaned? [) Yes ❑ No
Condition of System:
Good -
,. r-umped By
Name 'v'ciii�ic iicensa iJanter
�,OrY'l,any
i. Location where contents V✓eie disposed: -
Signature of Hauler
http://ww,/j.mass.go-v!del;'water/approvals/t!�forms.htri4inspect
t5form4.doc•06 03 5ystern Pumping Recoro-rage f of 1