HomeMy WebLinkAboutSeptic Pumping Slip - 55 STONECLEAVE ROAD 11/7/2016 Commonwealth of Massachusetts REOEIVED
City/Town of NOV '15 Z016
R
S i te °I'1 Pumping-Record TOWN F NORTH Ai�DOVER
Form 4 HEALTH DEPARTMENT
DEP has provided this form'for use-by local Boards of Health. Other forms maybe used, but the
informafi=must be substantially the same as that provided here. Before using.this form,check with your
local Board of Health to determine the foram they use.The System Pumping Record must be submitted to
the local Board of Health or other approving authority.
A. Facility. Information
I. System Location; Left ront of house eft/Right rear of house, Left/right side of house, Left/
Right side of building, Left I Right front of building, Left 1 Right rear of building, Under deck
Address
City[Town state Zip Code
2. System Owner.
- .,-.
Name'
Address(if different from location)
City/Town - State Zip Code
Telephone Number +�'
I'u
B. Pumping Kecord
1. Date of Pumping Bate 2. Quantity Pumped- Gallons
3. Type-of system. ❑ Cesspool(s) Q-Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yep o if yes, was it cleaned? ❑ Yes ❑ No;
5. Condition of System:
6. System Pumped By:
Nell.Bateson ` F5821
Name Vehicle License Number
Bateson Enterprises Ina
Company
7. Locatio • ere contents were disposed:
G LS- Lowell Waste Water
Sign jufe I Haute Date f
t6form4.doc 08/03 System Pumping Record•Page 1 of 1