HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 32 EQUESTRIAN DRIVE 8/20/2019 Commonwealth of Massachusetts RECEIVED
= City/Town of
System Pumping Record AU- 2 0 2019
Form 4 TOWN OF NORTH ANDOVER
�•• HEALTH DEPt,'
DEP has provided this form for use=by local Boards of Health. Other forms maybe*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 Information
1. System Location: Left/Right front of hous eftl ightGgar of house eft/right side of house, Left I
Right side of building, Left/Right front of building, Left/Right rear of building, Under deck
Address
C70frown state Zip Code
2. System Owner.
Name'
Address(if different from location)
Cityfrown state Zip Code
c 7o�'
Telephone Number
B. Pumping Record _
1. Date of Pumping pale 2. Quantity Pumped: Gallons
3. Type of system: ❑ Cesspool(s) l6ptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes LSO if yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
t��' ��✓� �- lam./
6. System Pumped By:
Neil.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Location where contents were disposed:
G L S F Lowell Waste Wafer
(i�� - - 19
Sign a cf HaulevDate
t5form4.doa-06/03 System Pumping Record•Page 1 of 1