HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 1116 SALEM STREET 10/7/2020 Commonwealth of Massachusetts RECEIVED
City/Town of OCT 0 7 2020
System Pumping Record TOWN OF NORTHANooVER
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/Right rear of house, Left side of house Left/
Right side of building, Left/Right front of building, Left/Right rear of building, Under eck
Address � i
t ( � -- �' - , �''� Cw � '�
Cityfrown State Zip Code
2. System Owner.
Name
Address(d different from location)
Cityfrown State Zi
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? ❑ Yes 0'i4o 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. LocatiQp vrhere contents were disposed:
Lowell Waste Water
Sign a 9t Haul Date
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