HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 25 ENGLISH CIRCLE 9/20/2019 Commonwealth of Massachusetts
City/Town of SEP 20 2019
System Pumping Record TOWN OF NORI H ANDuvER
Form 4 HEALTH DEPAR I MEN
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 06iotTront of house, eft/Right rear of house, Left/right side of house, Left./
Right side of building, ig Ilding, Left/Right rear of building, Under deck
Address
Cityfrown State Zip Code
2. System Owner.
Name
Address(if different from location)
Cityfrown State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping Date �epfic
uanti umped: Gallons
3. Type of system: ❑ Cesspool(s) Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes o If yes, was it cleaned? El Yes El No
5. Condition of System:
6. System Pumped By:
Neil.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc-
Company
7. LZeHaul
tents were disposed:
Lowell Waste Water
S Date
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