HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 56 GRAY STREET 4/1/2020 : Commonwealth of Massachusetts
E�EIVED
City/Town of
System Pumping Record ANC _ 12020
Form 4 TOWN OF NORTHANDOVER
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 Locatio .pe� Ri��66nof
eft/Right rear of house, Left/right side of house, LeftRight side of bu' , ett ing, Left/Right rear of building, Under deck
Address
Citylrown State Zip Code
2. System Owner. Q ^
Name"
Address(ir different from location)
CwTown State
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2. Q 'ty Pumped:
Gallons
3. Type-of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of Systpm: S
L—.
6. System Pumped By:
Neil.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Locati contents were disposed:
GLLS-P Lowell Waste Water
Sign a Haul pate
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