HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 46 WINTERGREEN DRIVE 11/12/2019 Commonwealth of Massachusetts RECEIVED
City/Town of
System Pumping Record NOV 12 2019
TOWN OF NORTH ANDOVER
Form 4 HEALTH DEPARTMENT
DEP has provided this form for use=by local Boards of Health. Other forms may beused, 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 hous ,L ft 1 Rf.Zt rear of hous , Left/right side of house, Left
Right side of building, Left/Right front of b�Fng, Left f Pight�building, Under deck
Address r\ � '�
City/Town �J state Zip Code
2. System Owner.
Name
Address(if different from location)
Citynown state zi
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
6. System Pumped By:
Neil.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Lo�n where contents-were disposed:
G L S: Lowell Waste Water
Sign a Haul Data
t5form4.doc•06/03 System Pumping Record•Page S of 1