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HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 24 FARNUM STREET 8/10/2020 : Commonwealth of Massachusetts RECEIVED City/Town of AUG 10 2020 System Pumping Record TOWN OF NORTHAND©VER Form 4 HEALTH DEPARTMENT DEP has provided this form for us&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 hou lg �, Left/right side of house, Left/ Right side of building, Left/Right front of bAlffig, Left/Right rear of buildin er d Address D 1_( Cdy/rown State Zip Code 2. System Owner Sal C4 Name' Address(if different from location) CWrown state'? l — uIN Telephone Number B. Pumping Record 1. Date of Pumping Date ;�eptic . Q 'ty Pumped: Gallons 3. Type of system: ❑ Cesspool(s) Tank ❑ Tight Tank ❑ Other(describe): 4. Effluent Tee Filter present? ❑ Yes o 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. Location wbpre contents-were disposed: /cLia-DLowell Waste Water '--f Ka SA �a a� Sign We cfHaulmUDate t5fbrm4.doc•06/03 system Pumping Record•Page 1 of 1