HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 52 BANNAN DRIVE 4/23/2020 _ Commonwealth of Massachusetts REC E-iVE®
City/Town of APR 9 2020
System Pumping Record TGWU NC)PIHANDOVER
Form 4 :.��,�, -PAR
DER 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 hous. , Left/rights a of h�JAeft
Right side of building, Left/Right front of building, Left/Right rear of g, Under k
Address
CRy/Town State Zip Code
2. System Owner.
Name
Address(d different from location)
Cit0own State- Zip Code
T�Isphone Number
B. Pumping Record
1. Date of Pumping Date 2• Quanti Pumped: Gallons
3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of /stem: a
UU j�
6. System Pumped By:
Neil Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Location-where contents were disposed:
`ji
Lowell Waste Water
Haul Date
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