HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 42 FULLER ROAD 10/29/2020 Commonwealth of Massachusetts RECEIVED
w City/Town of OCT 2 9 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 forrh 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:deft igh%rrIntof hous Left/Right rear of house, Left/right side of house, Left 1
Right side of buildIa Left/ o building, Left/Right rear of building, Under deck
Address
City/Town State Zip Code
2. System Owner.
Name'
Address(d different from location)
Cityfrown State�/ Zip Cod
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 a No if yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System: P(_�1� Ct� p n
6. System Pumped By:
Neil.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Location whom content&were disposed:
Lowell Waste Water
Signitufe 9t HauleV Date
t5form4.doc•06/03 System Pumping Record•Page 1 of 1
