HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 80 WINDKIST FARM ROAD 11/19/2020 Commonwealth of Massachusetts RECEIVED
ra City/Town of Nov 19 2020
System Pumping Record
Form 4 TOWN OF NORTH ANDOVER
lug HEALTH DEPARTMENT
DEP has provided this form for use-by local Boards of Health.Other forms may'be'used,but the
information-must be substardally 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 authonly.
A. Facility Information
1. System Locatio�Ri�n of house eft/Right rear of house, Left/right side of house, Left/
Right side of building, Left/Right front of building, Left/Right rear of building, Under deck
Address
City/rown State Zip Code
2. System Owner.
Name
Address(W different from location)
CitylTown State- A f�`I Z41P- �
Telephone Number _[
B. Pumping Record
1. Date of Pumping Babe 2. Quantity Pumped:
Gallons
3. Type of system: ❑ Cesspool(s) ptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes D_No If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System: ��,A
> ' A
6. System Pumped By:
Neil.Batesbn F5821
Name Vehide License Number
Bateson Enterprises Inc
Company
7. Loca' ere contents-were disposed:
G L S. Lowell Waste Water
l? -�e -
Sign a Flaul Dabs
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