HomeMy WebLinkAboutSeptic Pumping Slip - 65 EQUESTRIAN DRIVE 12/28/2016 Commonwealth of Massachusetts
n. M.(
Form 4 TOWN QF'NUH,[H ANDOVER
11EALIN DES-ARTM -r
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 forrh they use,The System Pumping Record must be submitted to
the local Board of Health or other approving authority.
. A. Facfl Information,
9. System Location L l ig fr .. pf hoes , Left 1 Right rear of house, Left f right side of house, Left I
t Right side of boil g, Left/Rlglg ron of building, Left/Right rear of building, Under depk
C
Address �e ,�•. � '`� - `'
Cityrrown state Zip Code
. System Owner:
Name
Auddress(if different from location)
City/Town State , Zip Code
Telephone Plumber
i
® Pumping_.1 Record
1. Date of Pumping 2. Qusnti Pumped: 6'
Crate Gallons
. Type•of system•: El Cesspool(s) Septic Tank El Tight Tank
El Other(describe):
4. Effluent Tee Filter present? El Yep 0 If yes, was it cleaned? [] Yes No,
5. Condition of System: „
6: System Pumped 6y:
Dell.Batesbn - F5321
Darns Vehicle License Plumber
Eateson Enterprises Inc-
Company
7.
' Lo t►gr' re contents-were disposed:
JG, : Lowell e'ste Water
sign
F
Fteule Cate
15formCdoo-06/03 System Pumping Record«rage 1 of 1