HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 405 SALEM STREET 5/18/2020 : Commonwealth of Massachusetts E9w� D
City/Town of MAY 18 2020
System Pumping Record TOWN OFNORtHANDOVER
Form 4 HEAjH E)cPPRTME":r
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: Le It2jj aht nt o�house ft/Right rear of house, Left/right side of house, Left/
Right side of building, Left/Right front of building, Left/Right rear of building, Under deck
Address Lf
City/Town State Zip Code
2. System Owner. �-
Name. U
Address(if different from location)
CWTown State' rZip Code
�
Telephone Number
B. Pumping record
1. Date of Pumping Date 2. Quantity Pumped:
Gallons
3. Type of system: ❑ Cesspool(s) eptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes LS No If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
6. System Pum e1i B .
Y P Y"
Neil.Batesbn F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Lo , e contentsrwere disposed:
L S Lowell Waste Water
Sign a Haut Date
t5fomm4.docr 06/03 System Pumping Record•Page 1 of 1