HomeMy WebLinkAboutSeptic Pumping Slip - 119 LIBERTY STREET 11/14/2016 Commonwealth of Massachusetts
4 City/Town of . RECEIVED
NOV 17 Z016
System Pumping.Record
Form 4 TOWN OF NUR�H ANDOVER
HEALTH DEPARTMENT
DEP has provided this form fior use=by local Boards of Health. other forms may be`used, but the
informatfon�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 kf ht_ ear 4, Left/right side of house, Left/
Right side of building, Left/Right front of building, Left/Right rear of building, Under deck
Address / �
City/rown State Zip Code
2. System Owner.
Name'
Address(if different from location)
city/Town ` State
Zip
Telephone Number
1
'.
.B, Pumping [record
1. Date of Pumping pate 2. Quantity Pumped: Gallons
3. Type-of system: ❑ Cesspool(s) ,Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? YerE] o If yes, was it cleaned? es ❑ No,
5. Condition of Systems:
6. System Pumped By:
Nell.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Lo tion).!her contents-were disposed:
G�& � Lowell Waste Water
Sign a I HaulerU Date
t5form4.doc•06/03 System Pumping Record•page 1 of 1