HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 40 EQUESTRIAN DRIVE 4/19/2022 RECEIVED
Commonwealth of Massachusetts
City/Town of APR 19 2022
System Pumping Record ;OWN OF NORTH ANDO`JER
HEALTH DEPARTMENT
Form 4
DEP has provided this form for use-by local Boards of Health. Other forms may *used,but the
information-must be substantially the same as that provided here. Before using.this form,check with yo
local Board of Health to determine the form they use. The,system Pumping Record must be submitted
the local Board of Health or other approving authority.
A. Facility Information
1. System Location: Left/Ri Ouse, Left/ Right rear of house, Left/right side of house, Lei
Right side of building, Le Right front f building, Left/Right rear of building, Under deck
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2. System Owner:
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Name
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Address(if different from location)
MA
City/Town State Zip Code
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Telephone Number
B. Pumping Record ' 4
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Component: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other (describe):
4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component pump
6. System Pumped By:
David Tiney _ Mass F5821
Name Vehicle License Number
Bateson Enterprises, Inc.
Company
7. Lo 'on where contents were disposed:
GLSD Lowell Waste Water
Signature of Hauler Date