HomeMy WebLinkAboutSeptic Pumping Slip - 49 ABBOTT STREET 5/24/2017Comm° wealth of Massach
City/Town of
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1AY .21 2011
TOWN 01- NU K H ANDOVER
HEALTH DEPARTMENT
DEP has provided this form 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 Infor tatiop
1. System Location: Left / Right front of house, Left / Right rear of house, Left5Qicrside of ho_us, Left /
Right side of building, Left / Right front of building, Left / Right rear of building, Under deck
2. System Owner:
Name'
Address (if different ro 10 tion)
City/Town
P
,••
d
1. Date of Pumping
Date
Telephone Number
2. Quantity Pumped:
3. Type.of system: 0 Cesspool(s) eptic Tank Ej Tight Tank
El Other (describe):
4. Effluent Tee Filter present? 0 Ye,, EJ
5. Condition of System:
If yes, was it cleaned? E] Yes 0 No,
6: System Pumped By:
Neil. Bateson
' Name
Bateson Enterprises Inc
Company
7. Lo 4ionihr contents were disposed:
Lowell Waste Water
F5821
Vehicle License umber
t5form4.doc• 06/03 System Pumping Record • Page 1 of 1