HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 84 CANDLESTICK ROAD 12/10/2019 RECEIVED
: Commonwealth of Massachusetts
City/Town of DEC 10 2019
System Pumping Record TOWN OFNORTHANDOVER
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: Lek ;g!/:h
��ofouseLeft/Right rear of house, Left/right side of house, LeftRight side of building, Le lding, Left/Right rear of building, Under deck
Address
owrown State Zip Code
2. System Owner.
Name
Address R different from locafion)
CiwTOwn � Zi Code
c
Telephone Number
B. Pumping Record l
1. Date of Pumping Date 2. Qu ty Pumped: Gallons
3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes o 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. Locati a contents were disposed:
G L S. Lowell Waste Water
u6z-,��
C�
Signitufe Haul Date
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