HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 192 LACY STREET 8/2/2019 RECEIVED
. Commonwealth of Massachusetts JUL 31 201
City/Town of
NDOVER
System Pumping Record �� �� �WN�a s°t�� �al�MENT
Form 4
DEP has provided this form for umby 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 Information
1. System Location: Left/Right front of house, I g ea o hous Left/right side of house, Left 1
Right side of building, Left/Right front of building, Left rear of building, Under deck
Address
Mylrown State Zip Code
2: System Owner.
Name'
I
Address(if different from location)
Cityrrown Zip Code
Uf_a
Telephone Number
.B. Pumping K-ecord
1. Date of Pumping gate 2. Quantity Pumped: f
Gallons
3. Type-of system: ❑ Cesspool(s) ptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes o If yes,was it cleaned? ❑ Yes ❑ No
5. Condition of System:
S. System Pumped By:
Neil.Batesbn F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. L er contents-were disposed:
M L S Lowell Waste Water
Slgn a Haul
Date
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