HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 86 FULLER ROAD 5/18/2020 :N Commonwealth of Massachusetts RECEIVED
City/Town of MAY 18 2020
System Pumping Record
Form 4 TOWN OF NORTH ANDOVER
HEALTH DEPARTMENT
DEP has provided this form for use-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/fgh7t ront of house ft/Right rear of house, Left/right side of house, Left
Right side of building, Left g ronTdf building, Left/Right rear of building, Under deck
Address City/Town State Zip Code
2. System Owner.
Name
Address(W different from location)
CWown
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 If yes,was it cleaned? ❑ Yes ❑ No
5. Condition of System:
6. System Pumped By:
Neil.Bateson F5821
Name Vehicle Ltoense Number
Bateson Enterprises Ina
Company
7. Loca' ere contents-were disposed:
G L S Lowell Waste Water
� a,
Sign a Haul Date
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