HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 71 WINTERGREEN DRIVE 11/19/2019 :�L\ Commonwealth of Massachusetts RECEIVED
City/Town of NOV 19 2019
System Pumping Record TOWN OF NORTH ANDOVER
Form 4 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 your
local Board of Health to determine the forrn 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 a 'Right ran��house,�, L ft/Right rear of house, Left/right side of house, LeftRight side of buiteeft/Rigng, Left/Right rear of building, Under deck
9 g.
Address
Cityrrown ate Zip Code
2. System Owner.
Name"
Address(if different from location)
CWown Stet qq��_ ype
Telephone Number
B. Pumping record
1. Date of Pumping Date �epljc
Pumped: Gallons
3. Type of system: ❑ Cesspool(s) ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes o If yes,was it cleaned? ❑ Yes ❑ No
5. Condition of System: r
6. System Pumped By:
Neil.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc'
Company
7.afi' whontent were disposed:
Lowell Waste Water
pate
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