HomeMy WebLinkAboutSeptic Pumping Slip - 17 SUGARCANE LANE 11/7/2017 Commonwealth of MassachusettsRECEIVED
v CitY/Town of .
S stem Pumping-Record NOV0 7 1
Forrn 4 TOWN
O NORTH ANDOVER
H TH DPA4 "GMNT f
DEP has provided this form far 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, informi anon
i
I. System LocatiaQg�g, Left
ig fr t bf h uo se Left/Right rear of house~, Left/righ#side of house, Left/
Ri ht side of bu /R ht Eton o uiidlrig, Left/Right rear of buildin , Under deck
g 9 g
Address
`r -
City/Town — `� State Zip Code
2. System Owner:
Name'
Address(if different from location)
City/Town State- Zip Code
Telephone Number
. .. f'.
i
Pumping record �..
1. Date of Pumping Date 2. Quantity Pumped: Gallons --`"
3. Type-of system. Cesspool(s) is Tank ® Tight Tank
El Other(describe):
4. Effluent Tee Filter present? [I Ye.;; allo If yes,was it cleaned? ® Yes {l No,
5. Condition of stem:
6: System Pumped By:
Neil.Batesbn ' F5821
Name Vehicle License Number
Bateson Enterprises Inc-
Company
7. here contents-were disposed:
7m. Lowell Waste Water
I
Sign a Hanle Date
t5form4.doc-06/03 System Pumping Record Page 9 of 1