HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 42 FULLER ROAD 10/12/2021 Commonwealth of Massachusetts RECEIVED
City/Town of
1W System Pumping Record
Form 4 TOWN OF NORTH ANDUVER
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 you
local Board of Health to determine the forth they use. The System Pumping Record must be r
submitted to
the local Board of Health or other approving authority.
A. Facility Information
1. System Location; Le Right ron of tious Left/Right rear of house,
Left/right side Right side of building, Left/Right ron of building, Left/Right rear of building Under decko house, Left/
Address 14 �i— � �
City/Town State
Zip Cotle
2. System OWner.
Name' �l
Address(if different from location)
City/Town Starr;
[7 �Zi�Code
o
Telephone Number
.B. Pumping Record
1. Date of Pumping 2. Quantity Pumped:
Date Gallons
3. Type of system: ❑ Cesspool(s) eptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes D, If yes, was it cleaned?
❑ Yes ❑ No
5. Condition of System: �l
6. System Pumpe�By;
F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Location where contentsrwere disposed:
L S. we aste Water
Sign e 9 e Date
form4.doa 06103
System Pumping Record.page 1 of 1