HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 93 WINTERGREEN DRIVE 11/30/2020 Commonwealth of Massachusetts RECEIVED
City/Town of
System Pumping Record Nov 3 0 2020
Form 4 TOWN OF NORTH ANDOVER
HE4LTH DEPARTMENT
DEP has provided this form for use-by local Boards of Health. Other forms may be'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/Righffrioint of house, Left/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
CitylTown —'S State Zip Code
2. System Owner.
Name V
Address(if different from location)
CiVrown State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping l l Quantity Pumped: tU
Date Gallons
3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes 0 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. Location"re contents-were disposed:
Lowell Waste Water
Sign a Haul Date
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