HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 427 WINTER STREET 1/13/2020 Commonwealth of Massachusetts RECEIVED
City/Town of JAN 13 2020
System Pumping Record TOWN OF NORTH ANDOVER
Form 4 HEALTH DEPARTMENT
I V_
DEP has provided this form for use-by local Boards of Health.Other forms may be used,but the
information must be substantially the two 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 house, LeVeff
rear of house, Left/right side of house, Left/
Right side of building, Left/Right front of buildiRight rear of building, Under deck
Address r r l-7 1 ' �
atylrown State Zip Code
2. System Owner.
Name*
Address(f different from location)
CiWown Zip Code
� (0 7?�
Telephone Number
B. Pumping record t CD
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 o If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
6. System Pumped By:
Neil.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Ina
Company
7. Locati w contents`were disposed:
C L S Lowell Waste Water
Sign a Haul Date
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