HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 312 FOSTER STREET 8/10/2020 Commonwealth of Massachusetts
RECEIVED
City/Town of AUG 10 2020
System Pumping 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 Locatio ont of hou e'It se eft/Right rear of house, Left/right side of house, Left
Right side of buil ing, Left Right ron uilding, Left/Right rear of building, Under deck
Address
City/Town State Zip Code
2. System Owner.
Name
Address(if different from location)
City/Town State-
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Type of system: ❑ Cesspool(s) ❑��beptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes [P46--- If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
6. System Pumped By:
Neil.Bates-on F5821
Name Vehicle License Number
Bateson Enterprises Inc-
Company
7. 7G,
re contents were disposed:
S. � Lowell Waste Water
r7—
Signitute crHaulerUDate
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