HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 40 DUNCAN DRIVE 6/24/2021 Commonwealth of Massachusetts
City/Town of RECEIVED
System Pumping Record JUN 2 4 2021
Form 4
TOWN OF NORTH ANDUVER
DEP has provided this form for us&by local Boards of Health. Other forms May be 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, Le t ht rear of house Left/right side of house, Left
Right side of building, Left/Right front of building, Left g rear of building, Under deck
Address
Cnylrown State Zip Code
2: System Owner.
Name'
Address(if different from location)
CiiyfTown
Code
Telephone Number
B. Pumping Record
1. Date of Pumping 2 Quantity Pumped:
Date Gallons
3. Type-of system: ❑ Cesspool(s) atepiic Tank ❑ Tight Tank
❑ Other(describe): /
4. Effluent Tee Filter present? El Yes ❑moo If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
6. System Pumped By:
Neil.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Ina
Company
7. Loca" we contents-were disposed:
GLUSQ Lowell Waste Water
t'
Sign We cf TiauleV Data
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