HomeMy WebLinkAboutSeptic Pumping Slip - 18 PENNI LANE 11/21/2017 Commonwealth of Massachusetts RECEIVED
itj/Town of
Sy/ tem Pumpling-Record TOWN OF HANDOVER
Form 4 HEALTH DEPAMMEN"F
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.
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A. Facility Information .
I. System Location: Left/Right front of house, Left �tMjsj�, Left I right side of house, Left/
Right side of building, Left/Right front of building, Left/Right rear of building, Under deck
Address
-ley
City/Town State Zip Code
2. System Owner: 1
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Name` 1
Address(if different from location)
City/Town State /yy//'J7 Ziip Code
Telephone Number
e Pumping R-9cord -
1. Date of Pumping gate 2. Quantity Pumped:
Gallons
3. Type�of system. ® Cesspool(s) �irTank ® Tight Tank
® Other(describe):
4. Effluent Tee Filter present? ® Yes a If yes, was it cleaned? ❑ Yes 0 Na,
' S. Condition of System: n / �v..�.. ����� �, `I/�,,,• �t�h.��.,..
6: System Pumped By:
Nell.Bateson F5821
Name Vehicle license Number
Bateson Enterprises Inc.
Company
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7. Lacati r�- here contents-were disposed:
G S: Lowell Waste Water
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Sign a Houle Date
t5f6rm4.doc•05103 System Pumping Record•Page 9 of 1
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