HomeMy WebLinkAboutSeptic Pumping Slip - 10 DUNCAN DRIVE 11/7/2017 Commonwealth of Massachusetts
City/Town of . RECEIVED
Sy tem P-umpin§,Record NOV 0 7 2011
Form 4
TOWN F NORTH ANDOVER
`fH LPART' �pT
DEP has provided this form'for useaby local Boards of Health. other for ay%e uses,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 forrim they use.The System Pumping Record must be submitted to
the local.Board of Health or other approving authority. 1
t
A. Facility Inform' atlon f
I. System Location: Left/Right front of house, Left]Right rear of house, Left/r�ht side of houses Left/
Right side of building, Left/Right front of building, Left/Right rear of building, lJnder deck
Address
to u
City/Town state Zip Code
2. System Owner:
Name'
Address(if different from location)
City/Town ' State• a, p
Zi Code
Telephone Number `4
. Pumping Record
1. Date of Pumping Date 2. Qu'ntity Pumped, ~ �
Gallons ; ' "
3. Type-of system: ® Cesspool(s) eptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ® Yes [3 o If yes, was it cleaned? ❑ Yes ® No,
' 5. Condition of System:
6. System Pumped By:
Neil.Bateson F5821
Name Vehicle License Number
Bateson Ehterprlses Inc,
Company
7. Lo io where contents were disposed:
*0 ) Lowell Waste Water
SigDate
Sform4.doc•06/03 System Pumping Record*Page 1 of 7