HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 59 EVERGREEN DRIVE 2/24/2020 Commonwealth of Massachusetts RECEIVED
_ City/Town of FEB 2 4 2020
System Pumping Record
Form 4 3n,�N OFNORTHANDOVER
a prpARTMF-NT
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 Ahis 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, Le ig rear of house,•Left/right side of house, Left,/
Right side of building, Left/Right front of building,Left Ig rear of building, Under deck
Address —
Cityrrown State Zip Code
2: System Owner.
Name
Address(if different from location)
CitylTown State 667 C) t— � Zip Code
Telephone Number
B. Pumping record
cl
1. Date of Pumping Date 2. Quanti Pumped: Gallons
3. Type of system: ❑ Cesspool(s) eptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes E3-'No if yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System, f /
6. System Pumped By:
Neil.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. L&eH
ents were disposed:
Lowell Waste Water
Si Date
t5fbrm4.doc-06/03 System Pumping Record•Page 1 of 1