HomeMy WebLinkAboutSeptic Pumping Slip - 42 FULLER ROAD 11/17/2017 Commonwealth of MassachustetfS D
_ Oty/Town of
System Pumpin+§.Record TQWNUNORTHANDOVER
Form 44
DEP has provided this form for use-by local Boards of Health. Other forms may be'used,but the f
information,must be substantially the same as that provided here. Before using.this form, *
heck 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. Inform' ation
1. System Locatio • e � tighRlgMnt"0of`buildlhg,
b, Left/Right rear of,house, Left./right side of house, Left/
Right side of butt t�eft/ Left/Right rear of building, Under deck
Address -
r"
city/Town State Zip code
2. System Owner:
Name.
Address(if different from location)
citylTown State Zi Code
Telephone Number "
. Pumping Record , �
1, Date of PumpingDate 2. Quantity Pumped: Canons
3. Type-of system: ❑ Cesspool(s) eptic Tank ❑ Tight Tank
Q Other(describe):
4. Effluent Tee Filter present? ® Yes UNif yes, was it cleaned? ❑ Yes ® No,
5. Condition of System:
6: System Pumped By:
Nell.Bateson - F5821
Name Vehicle License Number
Bateson Enterprises Ina
Company
7. Lo tion"W" Ibb contents were disposed:
C L S. Lowell Waste Water
Sig4tu a HaulerU Date F
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