HomeMy WebLinkAboutseptic tank - Septic Pumping Slip - 41 CEDAR LANE 10/1/2019 Commonwealth of Massachusetts
City/Town of OCT 0 i 2019
System Pumping Record TOWN OF NGF H ANDOVER
Form 4 HEALTH DEPAR T MIENT
DEP has provided this form for usez by local Boards of Health. Other forms may beused, 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 1
Right side of building, Left/ Right front of building, Left/Right rear of building, Under deck
Address
CWrown State Zip Code
2. System Owner. rr
Name
Address(if different from location)
City/Town State Tip Code
P7
Telephone Number
B. Pumping Record
1. Date of Pumping Date ( L 2. Quanti Pumped: Gallons
3. Type of system: ❑ Cesspool(s) t eptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes 0 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. Lo e contents were disposed:
G L S Lowell Waste Water
Sign a fl-laulmU Date
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