HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 225 HAY MEADOW ROAD 8/16/2021 Commonwealth of Massachusetts RECEIVED
City/Town of AUG 16 20
System Pumping Record TOWN OF NORTH ANDOVER
Form 4 H TH DEPARTMENT
DEP has provided this form for usezby 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, Left knight rear of ouse'Left/right side of house, Left
Right side of building, Left/Right front of building, Left/Right rear of building, Under deck
Address ,� [ �1 r ��-� (' W C
CWrown State Zip Code
2. System Owner.
,Q
Name
Address(if different from location)
CiVrown StateCode
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 (�t�a f 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. Location where contents-were disposed:
G L S Lowell Waste Water
a
SignAqe qt Haul Date
t5form4.docr 06/03 System Pumping Record•Page 1 of 1