HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 130 HAY MEADOW ROAD 5/18/2020 7)ECEIVED
Commonwealth of Massachusetts i°iY 18 2020
City/Town of
TOWN OF NORTH ANDOVER
System Pumping Record HEALTH DEPARTMENT
Form 4
19-
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 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 hou �elgt, efft
rear of .eft/right si ouse, Left/
Right side of building, Left/Right front of bu /Right rear of buildin rider deck
Address
City/rown �i State Zip Code
2. System Owner.
Name.
Address(if different from locafion)
CitylTown State�C�
Telephone Number C�
B. Pumping record _
1. Date of Pumping 2 QuantityPumped:
Dam p Gallons
3. Type-of system: ❑ Cesspool(s) 9-s-eptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
6. System Pumped By:
Neil.Mason F5821
Name Vehicle License Number
Bateson Enterprises Ina
Company
7. Locatio where contents were disposed:
G L S Lowell Waste Water
Sign a Haul Date
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