HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 50 BROOKVIEW DRIVE 11/30/2020 : Commonwealth of Massachusetts RECEIVED
lugCity/Town of NOV 3 0 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 maybe used,but the
information,must be substantially the same as that provided here. Before using.this form,check with your
focal 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 authorlty.
A. Facility Information
1. System Location: tft,
'gh nt of house Left/Right rear of house, Left/right side of house, Left
Right side of bulgy ' Left/Rlg o uildirig, Left/Right rear of building, Under deck
Address /�� k _f
City/Town (�J State Zip Code
2 System Owner.
e
Name
Address(if different from location)
Cityfrown Stalw Zip Code
Telephone Number
B. Pumping Record
V -r7--62
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? 0 Yes No If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
S. System Pumped By:
Neil.Batesbn F5821
Name Vehicle License Number
Bateson Enterprises Ina
Company
7. Location contents were disposed:
.L S: Lowell Waste Water
LA/USA. Bz6z_o-��
f Sign We qf HaulmU Data
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