HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 55 FULLER ROAD 10/12/2021 : Commonwealth of Massachusetts
City/Town of RECEIVED
system Pumping Record - i
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 forrh 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,(i�$0 Right Kjj of ous , Left/right side of house, Left
Right side of building, Left/Right front of building, Left/Right rear of building, Under deck
Address b Si ..q� _ C!�, /� ►�
CitylTown �(J l state Zip Code
2. System Owner.
Name'
Address(if different from location)
CiVrown State- _ip 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 alllo If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
6. Systeqn Pumped By
F5821
Name i Vehicle License Number
Bateson Enterprises Inc'
Company
7. Location where contents,were disposed:
GL�S.P A L well Waste Water
Sign a jaui Date
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