HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 7 DUNCAN DRIVE 8/10/2020 .A\- Commonwealth of Massachusetts RECEIVED
City/Town of AUG 10 2020
System Pumping Record TOWN OF NORTH ANDOVER
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 irmhou Left/Right rear of house, Left./right side of house, Left
Right side of building, Left/Right front of building, Left/Right rear of building, Under deck
Address
citylrown State Zip Code
2. System Owner. pa C 1 S
Name'
Address(if different from lowflon)
CWrown Sta*q
Zi Code
Telephone Number
B. Pumping Record
1. Date of Pumping pate 2. Quantity Pumped:
Gallons
3. Type-of system: ❑ Cesspool(s) teptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes DING If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
6. System Pumped By:
Neil.Bateson F5821
Name Vehide license Number
Bateson Enterprises Ina
Company
7. Lo ontentsrwere disposed:
G L S Lowell Waste Water
sign a Haulev Date
tftrm4.doa 06/03 System Pumping Record•Page 1 of 1