HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 22 FULLER ROAD 4/23/2020 : Commonwealth of Massachusetts RECEIVED
City/Town of
System Pumping Record APR 21 2020
Form 4 TOWN OF NORTH ANDOVER
y RTMENT
DEP has provided this form for umby local Boards of Health. Other forms maybe'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 Locatio • efa of ousel loft/Right rear of house, Left/right side of house, Leff
Right side of bu , Left/ g o ul ding, Left/Right rear of building, Under deck
Address f �
cityRown State Zip Code
2. System Owner.
Name
Address(if different from location)
CwTown gZin
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped:
Gallons
3. Type-of system: ❑ Cesspool(s) ptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes L.f'No If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
6. System Pumped By:
Neil.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Location_ where contents-were disposed:
G.L S Lowell Waste Water
Sign acpauleiuDate
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