HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 68 TUCKER FARM ROAD 12/16/2020 : Commonwealth of Massachusetts RECEIVED
City/Town of
System Pumping Record DEC 16 2020
Form 4 TOWN OF NORTH ANDO VER
�DIRTM Ell T
DEP has provided this form for use-by local Boards of Health. Other forms may'be'used,but the
information-must be substantially the two as that provided here. Before using.this form,check with your
local Board of Health to determine the foram 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 house6w�,,_Right 09irrf ouse Left/right side of house, Left/
Right side of building, Left/Right front of building, Left/Right building, Under deck
Address
�
City/Town Slate Zip Code
2. System Owner.
Name'
Address(Jr different from location)
CitylTown state Zi Code
Telephone Number
B. Pumping Record
1. Date of Pumping Dal 2 Qu tity Pumped:
Gallons
3. Type-of system: El Cesspool(s) Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes 01, o If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
6. System Pumped By:
Neil.Batesbn F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. LZcafiio here contents were disposed:
S. Lowell Waste Water
Signitufe it Hib Date
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