HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 10 DUNCAN DRIVE 8/24/2020 Commonwealth of Massachusetts RECEIVED
City/Town of AUG 2 4 2020
System Prim ping 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 autho ft.
A. Facility Information
1. System Location: Left/Right front of hou=bGg1_, L6eft1
e"�hous�eeft/right side of house, LeftRight side of bul�ding, Left/Right front of luiiding, Under deck
Address ^ `
CftyRown State Zip Code
2. System Owner.
Name —
Address(if different from location)
Cityrrown State n Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping Datei �c Quantity Pumped: sc c�
Gallons
3. Type-of system: ❑ cesspool(s) Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes 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 Ina
Company
7. Location-where contents-were disposed:
GLLS.P Lowell Waste Water
Sign aCfHauleruDate
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