HomeMy WebLinkAboutSeptic Pumping Slip - 45 TURTLE LANE 5/15/2017 Commonwealth of MauRECEIVED
C 1 n of
MAY 15 2 S '
SyMem Pumping. r TOWN OF NUKi H ANDOVER
Form 4 HEALTH DEPARTMENT 1
• 1
DEP has provided this form for use-by local Boards 6f Health. Other forms may be'lysed, but the
information-must be substantially the tame as that provided here. Before using.this form,check with year
local Board of Health to determine the form they use. The System Pumping Record must be subrnitte�d tc)
the local Board of Health or other approving authority.
A. r
Facility, Information
9. System Lo tic ° L Pig frpnt of Hous Left/Rlght rear of house, Left/right side of house, Left 1
Right side of building, Left/Rig ron of building, Left/dight rear of building, Under deck
Address
City/'rown Stele Zip Cod
2. System Owner:
Name'
Address(if different from location)
City/Town - State 1i
F Telephone Number
.6—. 0—umping
1. bate of Pumping date 2. Quantity Pumped: Gallons --"- -r
. Type s stern:
yp y. Cesspool(s) eptic°Tank Tight Tank
El Other(describe):
4. Effluent Tee Filter present? El 1(e Ido If yes, was it cleaned? 0 Yes 0 No,
. Condition of System°
eA- A U2,(J,�_
6: System Pumped By:
Nell.Bat d�n F5821
Name Vehicle License Number
Bateson Enterprises Inc-
Company
7.ZSigne
contents were disposed:
Lowell Waste dater
etJate F
t5form4.docb 06/03 System Pumping Record Page`i of I