HomeMy WebLinkAboutSeptic Pumping Slip - 55 WINTERGREEN DRIVE 10/16/2017OCT .1 6 ?O' 7
DEP has provided this form' for use.by local Boards CitHealth. Other forms may be Used, but the
TOWN OF NORTH ANDOVER
information' must be substantially the tame as that provided here. Before HuEsAi nLT91-.i th0 Ei Ps AfoRT:E,
NcTheck 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.
Commonwealth of Massachusetts
City/Town at
System Pumping. Record
Form 4
. A. Facility Information
. • ,---„i. .,.
1. System Locationev Right(frorit of house,'-teft / Right rear of house, Left / right side of house, Left /
Right side of buil ing, Left / Right frOnt of building, Left / Right rear of building, Under deck
Address
S 5 (1e('' dVICiO\i't<
City/Town'
2. System Owner:
Name
ttat 1.-ev
State Zip Code
Address (if different from location)
City/Town
•B. Pumping Record
1. Date of Pumping
3. Type -of system':
El •
E3 Other (describe):
61. t
Date
Cesspool(s)
4. Effluent Tee Filter present? Ci Yep
5. Condition of System:
6. System Pumped By:
Bateson
Name
Bateson Enterprises Inc
Company
7. Loca where contents were disposed:
Lowell Waste Water
State Zip Code
Telephone Number
Quantity Pumped:
Gallons
Septic Tank 0 Tight Tank
If yes, was it cleaned? 0 Yes El No,
F5821
Vehicle License Number
Date
t5form4.doc• 05/03 System Pumping Record • Page 1 of 1