HomeMy WebLinkAboutSeptic Tank / Pump Tank - Septic Pumping Slip - 162 ABBOTT STREET 10/7/2020 Commonwealth of Massachusetts RECEIVED
City/Town of OCT 0 7 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 Location: Left/Right front of house�e�'1-� t rear of house; Left/right side of house, Left
Right side of building, Left/Right front of building, Left/Rig rear of building, Under deck
Address l"
City/Town l� State Zip Code
2. System Owner.
Name
Address(if different from location)
CityiTown State^ VC �� p Code
Telephone Number
B. Pumping record
1. Date of Pumping Date 2. Quantity Pumped:
Gallons
3. Type of system: ❑ Cesspool(s) Q S'eptic Tank ❑ Tight Tank
11�LA-`'P �-Z-,
Other(describe): --N
4. Effluent Tee Filter present? ❑ Yes ❑ No If yes, was it cleaned? ❑ Yes ❑ No
5. Con n of stem:
6. System Pumped By:
Neil.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. L9cation w�-contents-were disposed:
OL�SQ Lowell Waste Water
Signaul Date
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