HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 249 CARLTON LANE 5/26/2020 Commonwealth of Massachusetts
RECEIVED
City/Town of MAY 2 6 2020
System Pumping Record TOWN OF NURT H ANDOVER
Form 4 HEALTH DEPARTMENT
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 hour , e /Rig rear�of house;left/right side of house, Left
Right side of building, Left/Right front of bbiltring, Left/Rtg�o building, Under deck
Address 2 ,
CiWTown State Zip Code
2. System Owner.
Name
Address(if different from location)
City/Town Stater rp Code
Telephone umber ,`I
B. Pumping record
1. Date of Pumping Date �2. uantity Pumped: �C)
Gallons
3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes [O/No If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
6. System Pumped By:
Neil Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc-
Company
7. Location where contents were disposed:
G_ P Lowell Waste Water
SignAtule 9f Haul pate'
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