HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 110 FULLER ROAD 11/19/2020 Commonwealth of Massachusetts RECEIVED
_ City/Town of NOV 19 ZQ ()
System Pumping Record TOWN OF NORTH ANDOVER
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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, Left C Right rear of house, Left/right side of house, Left 1
Right side of building, Left/Right front of building,Left/Right rear of building, Under deck
Address
City/Town State Zip Code
2. System Owner.
Name
Address(if different from location)
Citynown State Zip Code
Telephone Number
B. Pumping record
1. Date of Pumping pate � 2,'Quantity Pumped: y
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: p
6. System Pumped By:
Neil.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc-
Company
7. Location where contents were disposed:
G L S Lowell Waste Water
Sign aCf Haul Date
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