HomeMy WebLinkAboutSeptic Pumping Slip - 114 VEST WAY 11/9/2016 RECEIVED
.. Commonwealth of Massachusetts
NOV 15 2016
City/Town of .
. TOWN OF NUR I H ANDOVER S item Pumping-Record HEALTH DEPARTMENT
Form 4
DEP has provided this farm 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
I. System Location: Left l Right front of house, Left]Right rear of hous , Le �g Ide of hous Left/
Right side of building, Left/Right front of building, Left/Right rear of building, Un e
Address
l �.
ALI
City[Town State Zip Code
2. System Owner.
Name'
Address(if different from location)
city/Town State i de
Telephone Number
-
.B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped:
Gallons��—�`
3. Type-of system: ❑ Cesspool(s) eptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes 0'60 If yes, was it cleaned? ❑ Yes ❑ No
" 5. Condition ofSystem:
6. System Pumped By:
Nell.Bates-on F5821
Name Vehicle License Number
Bateson Enterprises Inc'
Company
7. Lo Lion re contents were disposed:
G.L SPiaui
Lowell Waste Water
Sign Date
t5form4.doc•06/03 System Pumping Record•Page 1 of 1