HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 143 DUNCAN DRIVE 7/8/2021 Commonwealth of Massachusetts RECEIVED
lugCity/Town of 1a 0 8 2021
System Pumping Record i®WNOF 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 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, ghitj§j r hd ho, Left/right side of house, Left
Right side of building, Left/Right front of bui!ding, Left/Righ rear of building, Under deck
Address � q3
UYIrrown state Zip Code
2. System Owner.
Name"
Address(if different from location)
CitylTown Stater
Telephone Number
6. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped:
Cations
3. Type of system: ❑ Cesspool(s) �-cTank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? �❑ No If yes, was it cleaned? 3—)k4 ❑ No
5. Condition of System:
6. System Pumped�By-
Neil.Bateson F5821
Name Vehide License Number
Bateson_ Enterprises Ina
Company
7. Location where contents-were disposed:
_L S Lowell Waste Water
4� -- a Z) --oaf
Sign a Hbut Date
t51brm4.doc-06/03 System Pumping Record•Page 1 of 1