HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 337 PLEASANT STREET 1/28/2020 : Commonwealth of Massachusetts
RECEIVED
City/Town of JAN 2 8 2020
System Pumping Record TOWN OF NORTHANDOVER
Form 4 HEALTH DEPARTMENT
CEP 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 houstrceRb5rigliinide of house- Left
Right side of building, Left/Right front of building, Left/Right rear of but mg, Under dec
Address
Citylrown Ff� __SSta�attee Zip Code
2. System Owner.
Name
Address(if different from location)
CWrown L(,r
--Code
Telephone Number
.B. Pumping record
1. Date of Pumping 2 Quanti Pumped:
Date Gallons
3. Type-of system: ElCesspool(s) ptic 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. Location where contents-were disposed:
4ne
S. Lowell Waste Water
ut Date
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