HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 98 FULLER ROAD 12/16/2020 Commonwealth of Massachusetts REvEIVED
City/Town of DEC 16 2020
System Pumping Record TOWN OF NORTH ANDOVER
Form 4 HF-ALTH 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 e r t of hou 8, Left/Right rear of house, Left/right side of house, Left
Right side of bui eft/ Ig ront of building, Left/Right rear of building, Under deck
Address
CWrown State Zip Code
2. System Owner.
D(_A,'�kC k
Name
Address(if different from location)
CiVrown State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2- Quantity Pumped: Gallons
3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes o If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
�� u V
6. System Pumped By:
Neil.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc-
Company
7. Location where contents were disposed:
_L S Lowell Waste Water
ign a Hauf Date
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