HomeMy WebLinkAbout- Septic Pumping Slip - 90 WINTERGREEN DRIVE 4/19/2022 RECEIVED
Commonwealth of Massachusetts
City/Town of APR 19 2022
6 System Pumping Record TOWN OF NORTH ANDCVER
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 yo
local Board of Health to determine the form they use.The System Pumping Record must be submitted
the local Board of Health or other approving authority.
A. Facility Information
1, System Location: Left/ t front of house, Left/ t rear�e, Left•/right side of house, Lei
Righ ide oZn
ding Right f nt of buildiri , efts Righ ear f building, Under deck
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2. Syst Owner:
N RP
Address(if different from location)
_ MA
CitylTown State _ � �d_3(90Q
Telephone Number 7�bj
B. Pumping Record 3
1. Date of Pumping Date �2. Quantity Pumped: Gallons
3. Component: ❑ Cesspool(s) ❑ Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe): --- -
4. Effluent Tee Filter present? Yes ❑ No If yes, was it cleaned? XYes ❑ No
5. Observed condition of component pumped.
24
6. System Pumped By:
David Tiney Mass F5821
Name Vehicle License Number
Bateson Enterprises, Inc.
Company
7. Loc here contents were disposed:
LSD Lowell Waste Water
Signature of Hauler Date