HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 35 TIFFANY LANE 9/9/2019 14 Commonwealth of Massachusetts RECEIVED
City/Town of
System Pumping Record
Form 4 TOWN OF NOW b ANDOVER
HEALTM DEPARTMENT
DER 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/Righ ront of house_ eft/Right rear of house, Left/right side of house, Left
Right side of building, Left/Rig t front of building, Left/Right rear of building, Under deck
Address (J �, l
CityJTown Sta a Zip Code
2. System Owner.
Name
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping e ` 2 uantity Pumped:
Date Gallons
3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes ❑ No If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
6. System Pumped By:
Neil.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Locatio"w#e contents were disposed:
G L S Lowell Waste Water
Sign a Haul Date
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