HomeMy WebLinkAboutSeptic Pumping Slip - 74 STONECLEAVE ROAD 11/17/2016 Commonwealth of Massachusetts
City/Town of . RECEIVED
System Pumpin§.Record 8 )lib
Form 4
TOWN CAE NORI H ANDOVER,
HEALTH DEPARTMENT
DEP has provided this form far 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. Informlation
7. System Location: Left/Right front of Crouse, Leftk!§iglhht rear of hou ; Left/right side of house, Left/
Right side of building, Left/Right front of building, Left/Rig rear of building, Under deck
Address
citylrown State Zip Code
2. System Owner.
Name.
Address(if different from location)
citylrown ` Stat Zi code
rah " -C
. s - ' `�"
Telephone Number +1.
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.B. Pumping ,Record
1. Date of Pumping date 2. Quantity Pumped: Gallons
3. Type-of system. ❑ Cesspool(s) ❑septrc Tank 0 Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yea If yes, was it cleaned? ❑ Yes ❑ No,
5. Condition of System:
0,12 � c
6; System Pumped By:
Nell.Bateson ' F5821
Name Vehicle Ucense Number
Bateson Enterprises Inc-
Company
7. Locapio 7re contents were disposed:
Lowell Waste Water
-eig—nkuhe I Hbulwu Date
t5form4.doo•06103 System Pumping Record•Page 1 of 1