HomeMy WebLinkAboutSewer Lift Station - Septic Pumping Slip - 50 WILD ROSE DRIVE 7/2/2020 :A\, Commonwealth of Massachusetts RECEIVED
City/Town of JUL 0 1 2020
System Pumping Record TOWN OF NORTH ANDOVER
HEALTH DEPARTMENT
Form 4
DEP has provided this form for use-by local Boards of Health. Other forms may 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 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 gh# ront of hou , Left/Right rear of house, Left/right side of house, Left
Right side of building, Left Right of
of building, Left/Right rear of building, Under deck
Address
City/Town State Zip Code
2. System Owner.
Name" U l
Address(if different from location)
City/Town
Telephone Number
B. Pumping Record
1. Date of Pumping Date Quantity Pumped:
Gallons
3. Type of system: ❑ Cesspool(s) ❑ Septic Tank ❑ Tight Tank
Other(describe): <�! ' e-{- 4__�_JP� Ea-.A '_- �
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 Velude License Number
Bateson Enterprises Inc
Company
7. Location where contents-were disposed:
WHwIwU
Lowell Waste Water
SigDate
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