HomeMy WebLinkAboutSeptic Pumping Slip - 116 CHRISTIAN WAY 10/25/2017 Commonwealth of Massachusetts RECEIVED
_ Cit�/Town of . XT 001
` y' tem P'•umpin§-Record TOWN OF NORTHANDOVE
° Form 4 HEALTH DEPARTMENT
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®EP 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 Infarmmatian
I. System Location: Loft/Right front of douse, Left Cl igKi rear_qfhodjj0 Left/right side of house, Left•
Right side of building, Left/Right front of building, Left/Right rear of building, Under deck
Address ll f
city/Town State Zip code
2. System Owner:
Name'
Address(if different from location)
City(T'own ' state Zip Code
Telephone Number
,i
Pumping Rlcorld
t
1. Date of Pumping �� 0 Quantity Pumped: � t Cs�'�— =
Dae Gallons z.
3. Type-of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank
❑ Other(describe):
4.. Effluent Tee Filter present? C] Yes No If yes,was it cleaned? ® Yes ❑ No,
6. Condition of System.
6. System Pumped By.
Nell.Batesbn ' F5821
Name Vehicle Llcense Number
Bateson Ehterprises Inc,
Company
7. Location-where contents•were disposed:
CLS: Lowell Waste Water
Sign a Haule Date
5form4.doC 06/03 System Pumping Record•Page 9 of 1