HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 495 REA STREET 4/23/2020 RECEIVED
gL
Commonwealth of Massachusetts APR 212020
City/Town of
TOWN OF NORT H ANDOVER
System Pumping Record HEALTH DEPARTMENT
Form 4
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: Left/Right front of house,Left Rig e r of house; Left/right side of house, Left
Right side of building, Left/Right front of bud i3'ng, Left 1 Right rear of building, Under deck
Address
City/Town State Zip Code
2. System Owner.
Name
Address(if different from location)
City/Town Stale p Code
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes Q— d If yes, was it cleaned? ❑ Yes ❑ No
5. Condifion of Syst
r*)'-C>J-
6. System Pumped By:
Neil.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Location-where contents were disposed:
G L qHaul
Lowell Waste Water
Sign Date
t5f6rm4.doc•06/03 System Pumping Record•Page 1 of 1