HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 71 WILLOW RIDGE ROAD 9/25/2020 : Commonwealth of Massachusetts RECEIVED
IMMEMMEMMS
City/Town of Sg 2 5 2020
System Pumping Record Torl,OFNORTHANDOVER
Form 4 H�,LTH 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 Rig of house,Left/Right rear of house, Left/right side of house, Left 1
Right side of bull'ding, Left/Right front of building, Left/Right rear of building, Under deck
Address ` �(ck-c)
C'i y/Town a Zip Code
2. System Owner.
Name'
Address(4 different from location)
City/Town g C, C7 r�c `J
Telephone Number
.B. Pumping Record
1. Date of Pumping 2 Quantity Pumped:
Date Gallons
3. Type of system: ❑ Cesspool(s) Septic 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 Ina
Company
7. LoWH�Wwu
tent&were disposed:
Lowell Waste Water
SigDate
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