HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 70 WINDKIST FARM ROAD 9/22/2021 Commonwealth of Massachusetts RECEIVED
_ City/Town of SAP 2 2 20
v° System Pumping Record
TOWN OF NORTH ANDUvER
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 nt�houseLeft/Right rear of house, Left/right side of house, Left 1
Right side of building, Left/Right front of building, Left/Right rear of building, Under deck
Address 7
t/`�'o O
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) eptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes LSO 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 where contents were disposed:
6 G L� Lowell Waste Water
1 a- A. 6����� (—ts
Sig—n—VW*e— HaulevDate
t5form4.docr 06/03 System Pumping Record•Page 1 of 1