HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 46 WINTERGREEN DRIVE 9/25/2020 : Commonwealth of Massachusetts RECEIVED
City/Town of
System Pumping Record SEP 2 5 20ZU
Form 4 TOWN OF NORTH ANDOVER
HEALTH DEPARTMENT
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 forrh 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;-QtGRrgP near of ho , Left/right side of house, Left
Right side of building, Left/Right front of But rng, Left/Right rear of building, Under deck
Address
�rU V1
MYRown State Zip Code
2. System Owner. L_�,
Name
Address(if different from location)
C_WTown state
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:
6. System Pumped By:
Neil.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Locatioswhere contents were disposed:
Lowell Waste Water
SigMeHaWl Date
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