HomeMy WebLinkAboutseptic tank - Septic Pumping Slip - 224 HAY MEADOW ROAD 6/9/2020 Commonwealth of Massachusetts
City/Town of RECEIVED
System Pumping Record SUN 0 9 2020
Form 4
TOWN OF�fORTH ANDUVER
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 house Flight ear�of house, Left/right side of house, LeftRight side of building, Left/ Rightfront of bui Ing, Left/Rear of building, Under deck
Address ,Da mil `- U P c� -'v�l `'� �`
r—
City/Town State Zip Code
2. System Owner.
Name
Address(if different from location)
City/Town State- f--, C Zip Code
� 9
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2_ Quantity Pumped: Gallons
3. Type of system: ❑ Cesspool(s) tic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes o If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
6. System Pumped By:
Neil.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Loca ere contentawere disposed:
Lowell Waste Water
r
Sign a Haul Date
t5form4.do(.-06/03 System Pumping Record•Page 1 of 1