HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 143 DUNCAN DRIVE 7/2/2020 :-CN- Commonwealth of Massachusetts RECEIVED
City/Town of JUL 0 1 202>>
System Pumping Record
TOWN OF NORTH ANDUVER
Form 4 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/Right front of house ft/ gh ear of house t.eft/right side of house, Left
Right side of budding, Left/Right front of bui�eft/Wg rear o build'mg, Under deck
Address / Lt _3 OC_)
City/rown State Zip Code
2. System Owner.
Name"
Address(if diffenant from location)
City/Town Stan����Q Zip Code
Telephone Number r
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? es ❑ No If yes,was it cleaned? (-yes-lb No
5. Condition of System-
6. System Pumped By.-
Nell.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Location where contents-were disposed:
L S Lowell Waste Water
OUSign a Haul Date
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