HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 90 WINDSOR LANE 12/7/2020 :� Commonwealth of Massachusetts RECEIVED
_ City/Town of
System Pumping Record DEC 0 7 2020
Form 4 TOWN OF NORTH ANDOVER
r••v HEALTH DEPcr-Tr;-,NT
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/Right front of house, Left/Right rear of house, Left/ ht s left/
Right side of building, Left/Right front of building, Left/Right rear of building, Under deck
Address q�
City/Town State Zip Code
2. System Owner.
Name
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Type of system: ❑ Cesspool(s) 9-S'eptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of stem:
6. System Pumped By:
Neil.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc-
Company
7. Lo here contents were disposed:
G L S. Lowell Waste Water
�-K a- A.
c -
SignAtute It Htule4J Date
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