HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 7 DUNCAN DRIVE 8/16/2021 : Commonwealth of Massachusetts RECEIVED
City/Town of
System Pumping Record AUG 16 2021
Form 4 TOWN OF NORTH ANDOVER
HEALTH DEPARTMENT
DEP has provided this form for use-by local Boards of Health. Other forms maybe 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/Righ ron of hous Left/Right rear of house, Left/right side of house, Left/
Right side of building, Left/Right front of building, Left/Right rear of building, Under deck
Address
Citylrown State Zip Code
2. System Owner.
Name
Address(if different from location)
CitylTown State Zi Code
Telephone Number
6. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped:
Gallons
3. Type of system: ❑ Cesspool(s) eptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes LSO 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. Location where contents were disposed:
S Lowell Waste Water
CN raSA.
Sign We fHaulwU Date
t5formCdocr 06/03 System Pumping Record•Page 1 of 1