HomeMy WebLinkAbout- Septic Pumping Slip - 247 FARNUM STREET 11/26/2019 Commonwealth of Massachusetts RECEIVED
City/Town of Nov 2 6 Z019
System Pumping Record TOWN OF NORTHANDOVER
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, �rfight rid''Left I
Right side of building, Left/Right front of building, Left/Right rear of building, Under deck
Address
City/Town State tJ Zip Code
2. System Owner. � 0 J�
f�
Name
Address(if different from location)
CitylTown Stat f( j ,Zp�dgC
Telephone Number` �+
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Type of system: ❑ Cesspool(s) [3Sieiipitc Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes 0'40 If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
�' Jra-
6. System Pumped By:
Neil Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Locati where contents were disposed-
Low
G L S. Lowell Waste Water
Sign a Haul Date C
t5form4.doa 06/03 System Pumping Record•Page 1 of 1