HomeMy WebLinkAboutPump Tank - Septic Pumping Slip - 53 OLD CART WAY 8/20/2019 Commonwealth of Massachusetts RECEIVED..
City/Town of AUG 2 0 20%
System P-umptng-Record TOWN OF NORTHANDUVER
Form 4 HEALTH DEPARTMENT
r•. 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.
A. Facility. information
1. System Location: Left/Right front,of house, Left/Right rear of house, Left/right side of house, Left/
Right side of building, Left J Right front of building, Left/Right rear of building, Under deck
Address \ c
City/Town
State Zip-Code
` 2. System Owner. 'S -
i�
Name'
j Address(if different from location)
CityfTown State Z
/ ,, i fro
Telephone Number
1
1
r'
B. Pumping Record '
I. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Type-of system: ❑ Cesspool(s) ❑ Septic Tank ❑ Tight Tank
�Otherdescribe):
Yes ❑ No if yes, was it cleaned? ❑ Yes ❑ No,
4. Effluent Tee Filter present? ❑
' 5. Condition of System:
r
6: System Pumped By.
Neil.Bateson . F5821
Name Vehicle t_icense Number
Bateson Enterprises Ina
Company
I 7. Location where contents,were disposed:
G L S. . - Lowell Waste Water
i
sign a Haul
Date
t5f6rm4.docr 06/03 system Pumping Record•Page S of 1