HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 56 WINDKIST FARM ROAD 12/16/2020 : Commonwealth of Massachusetts RECEIVED
City/Town of DEC 16 2020
System Pumping Record TOWN OF NORTH ANDOVER
Form 4 HEALTH 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/Right front of house, Left/Right rear of house, Left/ h side of�ou Left/
Right side of building, Left/Right front of building, Left/Right rear of building, Under dec.K
Address F0 W �l-d�� —t/ �
City/town State Zip Code
2. System Owner.
C
Name.
Address(if different from location)
Cityfrown state �,� Code
Telephone Number
B. 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 Id"No If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
6. System Pumped By:
Neil.Batesbn F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Location where contents-were disposed:
G L S Lowell Waste Water
Sign Aa"Haul er U Date
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