HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 89 MARIAN DRIVE 8/4/2021 Commonwealth of Massachusetts RECEIVED
City/Town of AUG 0 4 2021
System Pumping Record TOWN OF NORTH ANDUVER
Form 4 HEM'T pEPARTMENT
DEP has provided this form for us&by local Boards of Health. Other forms may *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, Left i tit rear o ous , Left/right side of house, Left
Right side of building, Left/Right front of building, L Right rear of building, Under deck
Address pt/G�� � J�r
City/Town U fstate Zip Code
2 System Owner.
Name'
Address(if different from location)
CitylTown State r C f ^ Code f
Telephone Number (�
.B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped:
Gallons
3. Type-of system: ❑ Cesspool(s) eg;fic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ayes ❑ No If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of Sy �
6. System Pumped By:
Nell.Meson F5821
Name Vehicle License Number
Bateson Enterprises Ina
Company
7. Lo a contents-were disposed:
L Lowell Waste Water
Sign a Haul Date
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