HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 15 WINDKIST FARM ROAD 7/1/2020 RECEIVED
Commonwealth of Massachusetts JUL p 1 2020
City/Town of
NDOVER
System Pumping Record TOWN LT NORTHAMENT
Y P g HEALTH DEPARTMENT
Form 4
DEP has provided this form for use�by local Boards of Health. Other forms may 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 igh front of house Left/Right rear of house, Left/right side of house, Left
Right side of building, gt -f "building, Left/Right rear of building, Under deck
Address t W
Cttylrown State Zip Code
2. System Owner.
Name
Address(if different from location)
City/Town Code
Telephone Number
B. Pumping Record
1. Date of Pumping Date Z. Quantity Pumped: Gauons
3. Type-of system: ❑ Cesspool(s) eptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes L f'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. 7G,
econtent were disposed:
S. Lowell Waste Water(4Ha&A.
-'
�-
Signkje Haul Date
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