HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 40 DUNCAN DRIVE 6/9/2020 Commonwealth of Massachusetts RECEIVED
City/Town of J0N 0 0 2020
System P-umping Record TOWN OF NORTHANDOVER
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 house, Left/Right(§y of housetight f hous Left
Right side of building, Left/Right front of building, Left/Fught rear of building, Under deck--
Address f
Cityfrown State Zip Code
2. System Owner. V��u
Name
Address(if different from location)
CitylTown State Zip 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 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. Locati erP_contents were disposed:
r
G L S. Lowell Waste Water
5'-'3q -�
Sign a Haul Date
t5form4.doc-06/03 System Pumping Record•Page 1 of 1