HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 386 SHARPNERS POND ROAD 5/26/2020 : Commonwealth of Massachusetts
RECEIVED
_ City/Town of MAY 2 6 2020
System Pumping Record TOWN OF NURTHANDUVER
Form 4 HEALTH DEPARTMENT
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(Wight front of housai`Left/Right rear of house, Left/right side of house, Left
Right side of building, Left/Right front of building, Left 1 Right rear of building, Under deck
Address
City/Town F State Zip Code
2. System Owner r
OVA
Name'
Address(if different from location)
Cityfrown State ` Zip 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 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 L�S Lowell Waste Water
Signitufe fHauleVDate
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