HomeMy WebLinkAbout- Septic Pumping Slip - 338 BERRY STREET 10/31/2018 Commonwealth of Massachusetts
City/Town of RECENED
3 12018
System Pumpino Record OCT
Form 4 TOW�q OF NOM H ANDOVER
1,,1EALTH DEPAUMENT
DEP has-provided this form for use-by local Boards of Health. Other forms maybeused, but the
information,must be substantially the tame 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. Factlity InforMa'fit
on
1. System Location: Leh/Right front of house, Left]Right rear of hoes. rig hfiie`�"o_ Left I
Right side of building, Left/Right front of building, Left/Right rear 6 'uffc-ringi , Under deck
Address
citylT awn State Zip Code
2. System Owner
Address(if different from location)
CitylTown State 1p Code
Telephone Number
Pumping c®
1. Date of Pumping Date r_ Q�Uua ty Bumped: Gallons
pr le
3. Type-of system: Ej Cesspool(s) ; epfic Tank ❑ Tight Tank
El Other(describe):
4. Effluent Tee Filter present? El Yes o If yes, was it cleaned? Ej Yes El No
5. Condition of Syste
S. System Pumped By:
Nell.Betesbri F5821
Name Vehicle License Number
Bate§on Enterprises Inc
Company
7. Location ere contents-were disposed:
Lowell Waste Water
Sign e Hhulad j Date
\.Of
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