HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 93 WINTERGREEN DRIVE 11/19/2019 Commonwealth of Massachusetts
RECEIVED
City/Town of NOV 19 2019
System Pumping Record TOWN Of NORTH
HEAI.THDEPA ANDOVER
Form 4
TMENT
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 forrim they use. The.System Pumping Record must be submitted to
the local Board of Health or other approving autha ft.
A. Facility Information
1. System Location• a Righ ntrr�on_tofFbuildifig,
ouse�Left/Right rear of house, Left/right side of house, Left
Right side of bu ' g, Left/R► Left/Ri ht rear of buildin Under deck
99 9.
Address
cityfrom State Zip Code
2. System Owner.
Name
Address(if different from location)
CW Town
Telephone Number J
B. Pumping Record
1. Date of Pumping Date �2. ,Qlu�a'nfiPumped: Gauons
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 stem:
6. System Pumped By:
Neil.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Locatio he a contents were disposed:
�L S Lowell Waste Water
h
Sign a Haul Date
t5form4.dora 06/03 System Pumping Record•Page 1 of 1