HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 208 OLD CART WAY 10/30/2019 Commonwealth of Massachusetts RECEIVE®
City/Town of OCT 3 0 2019
System Pumping Record TOWN OFNORTHANDOVER
s..
Form 4 HEALTH DEPARTMENT
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 ode of hnuse�, Left
Right side of building, Left/Right front of building, Left/Right rear of building, Under deck
Address
Q S"
QWTown State Zip Code
2: System Owner.
Name
Address(if different from location)
City/Town $���` Zip��
Telephone Number
B. Pumping Record
1. Date of Pumping oat / 2. Quantity Pumped: Gallons
3. Type of system: ❑ Cesspool(s) eptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? es ❑ No If yes, was it cleaned? E1--Yes-0 No
5. Condition of System•
6. System Pumped By:
Neil.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. aSignitule
ontents-were disposed:
Lowell Waste Water
Date
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