HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 547 WINTER STREET 10/5/2021 Commonwealth of Massachusetts RECEIVED
City/Town of
System Pumping Record OCT 0 5 2021
Form 4 TOWN OF NORTH ANDOVER
�• HEALTH nr_pr.,RTMENT
DEP has provided this form for use=by local Boards of Health. Other forms may beused, but the
information must be substantially the same as that provided here. Before using.this form,check with your
focal 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/Rig ron of house ft/Right rear of house, Left/right side of house, Left
Right side of building, Left I Right ron of building, Left/Right rear of building, Under deck
Address
City/Town State Zip Code
2. System Owner.
Name
Address(if different from location)
CWrown State Zip Code
:2 v - �4(O
Telephone Number
B. Pumping Record
1. Date of Pumping Dater 2. Quantity Pumped: Gallonsl V
3. Type of system: ❑ Cesspool(s) Eq/septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes a 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 here contents-were disposed:
G L S. Lowell Waste Water
SignAtute 9t HauleV Date
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