HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 1465 FOREST STREET EXT 9/2/2020 : Commonwealth of Massachusetts RECEIVED
ra City/Town of SEP 0 2 2020
Sy t4 m Pwmping Record TOWN OF NORTHANDOVVER
Form
HEALTH DEPARTMENT
DER has provided this form for use-.by local Boards of Health. Other forms may *used,but the
information,must be substantially the two 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 �Ofu Left/right side of house, Left
Right side of building, Left/Right front of building, Left/Right rear of building, Under deck
Address
i J City/Town State Zip Code
Q�
2. System Owner. Ic�,(�/
fi1 �
9" Name
Address(if different from location)
Telephone Number
B. Pumping Record
1. Date of Pumping Date �QuainfiPumped: Gallons
3. Type of system: ❑ Cesspool(s) k ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes o If yes, was it cleaned? E) Yes ❑ No
5. Condition of System: -
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6. System Pumped By:
Neil.Batesbn F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Lo ere contents-were disposed:
G L S. Lowell Waste Water
Sign a Haul Date
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