HomeMy WebLinkAboutSeptic Pumping Slip - 234 HAY MEADOW ROAD 10/27/2016 : Commonwealth of Massachusetts
City/Town of . RECEIVED
System Pumping.Record XT 3 '1 U
`X Form 4
TOWN OF NORTH ANDOVER
DEP has provided this form for use-by local Boards of Health. Other forms ma %TWA; T N
lnforma6on 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, Leftl:fti gbt cear-of house, Left/right side of house, Left/
Right side of building, Left I Right front of building, Left/Right rear of building, Under deck
Address
Cityrrown State Zip Code
�a
2. System Owner.
Name
Address(if different from location)
Cityfrown
l to
Telephone Number
.B. Pumping Record
1. Date of Pumping Quanti Pumped:
--—.
Gallons ,
3. Type-of systen7. ❑ Cesspool(s) eptic Tank ❑ Tight Tank
❑ Other(describe).
4. Effluent Tee Filter present? ❑ Yes D' o.... If yes, was it cleaned? El Yes ❑ No,
5. Condition of System.
• 11`'�•-�i� `�� lam":�`
C
6: System Pumped By.
Neil.Bateson F6821
Name Vehicle License Number
Bateson Enterprises Inc-
Company
7. Lora. e contents were disposed.
G.L,S Lowell Waste Water
�--P/USA 6�����
Sign a Haule Date
t5form4.doc-06/03 System Pumping Record•Page 1 of 1