HomeMy WebLinkAboutSeptic Pumping Slip - 54 STERLING LANE 11/10/2016 Commonwealth of Massachusetts
City/Town of . RECEIVED
System Pumping.Record
Form 4 NOV I b ni
TOWN OF NUR'[H ANDOVER
DEP has provided this form for useGby local Boards of Health. Other forms rh h�&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
I. System Location: Left/Right front of house, Left/Og ear of hoc , , Left/right side of house, Left/
Right side of building, Left/Right front of building, Left/Right rear of building, Under deck
. Address ELI
city/Town State Zip Code
2. System Owner.
Name
Address(if different from location)
City/Town ' State Zip 15, de
Telephone Number J° .
r
1
.B. Pumping Record
1. Date of Pumping Date P. Quantity Pumped: Gallons
3. Type-of.system: ❑ Cesspool(s) ®.-Septic ank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yep 0-Mo If yes, was it cleaned? ❑ Yes ❑ No,
5. Condition of Systerry
6. System Pumped By:
Neil.Meson F5821
Name Vehicle License Number
Bateson Enterprises Inc`
Company
7. Locat_iott�uiere contents were disposed:
G.�s: " 1 Lowell Waste Water kF�=
9 SignAt4e Houle Date
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