HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 22 FULLER ROAD 4/28/2021 : Commonwealth of Massachusetts RECEIVED
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City/Town of APR 2 8 2021
System Pumping Record
Form 4 TOWN OF NORTH ANDUVER
HEALTH DEPARTMENT
DEP has provided this form for use-by local Boards of Health. Other forms may be bsed,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 Locatior�• e • #front of u Left'Right rear of house, Left/right side of house, Left/
Right side of bullifin�g, LL A o uildirig, Left/Right rear of building, Under deok
Address �-�-- `c--� �-� f /�_.
City/Town / State Zip Code
2. System Owner.
Name"
Address(if different from location)
CitylTown state, Code
Telmhone Number
B. Pumping Record
1. Date of Pumping vL 2 Date
Quantity Pumped: Gallons
s
3. Type-of system: ❑ Cesspool(s) eptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes 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. Location where contenter were disposed:
G L.SP Lowell Waste Water
Signitie it Hauf Date
t51orm4.doa 06/03 Systern humping Record•Page 1 of 1