HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 544 JOHNSON STREET 7/13/2020 Commonwealth of Massachusetts RECEIVE®
City/Town of JUL 13 2020
System Pumping Record TOWN OF NORTHANDUVER
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Form 4 HEALTH DEPARTMENT
DEP has provided this form for use=by local Boards of Health. Other forms may beused, 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 I-Right reaofr house, Left/right side of house, Left I
Right side of building, Left/Right front of building, Left?Right rear of building, Under deck
Address
EL4q ��i
City/Town State Zip Code
2. System Owner.
Name
Address(if different from location)
City/Town State Tip Code
Telephone Number
B. Pumping record
1. Date of Pumping Date 2. Quantity Pumped:
Gallons
3. Type of system: ❑ Cesspool($) ❑ 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. LoZL
o re contents-were disposed:
SJQ Lowell Waste Water
SignAtute Haul Date
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