HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 502 WINTER STREET 9/21/2020 .&\- Commonwealth of Massachusetts RECEIVED
City/Town of SEP 212020
System Pumping Record
Form 4 TOWN OF NORTH ANDOVER
HEALTH DEPARTMENT
DEP has provided this form for use-by local Boards of Health. Other forms may be'used,but the
information-must be substandW 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•�Rig nt o house, ft/Right rear of house, Left/right side of house, Left
Right side of building, Left/ ulldirig, Left/Right rear of building, Under deck
Address
cfty/rown State Zip Code
2. System Owner.
Name.
Address(if different from location)
City/Town Tip Code
Telephone Number
6. Pumping Record
1. Date of Pumping Date 2 Quantity Pumped:
Gallons
3. Type-of system: ❑ cesspool(s) eptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:Nn�
C� �
6. System Pumped By:
Neil.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7.aeHauWriffiff
ontents-were disposed:
Lowell Waste Water
-�
Date
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