HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 29 NORTH CROSS ROAD 8/10/2020 Commonwealth of Massachusetts RECEIVED
City/Town of AUG 10 2020
System Pumping Record TOWN OF NORTHANDUVER
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] ht rear of h use Left/right side of house, Left
Right side of building, Left/Right front of building, Left/Right rear of building, Under deck
Address
Cityrrown State Zip Code
2. System Owner.
Name'
Address(if different from location)
CiWTown State Zi 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? es ❑ No If yes, was it cleaned? 3-Ye-s ❑ No
5. Condition of stem:
6. System Pumped By:
Neil.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc-
Company
7. Locatign-where contents were disposed:
Lowell Waste Water
SignVqe qt Haul Date
t5f6rm4.doa 06/03 System Pumping Record•Page'i of 1