HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 146 OLYMPIC LANE 11/30/2020 .&\- Commonwealth of Massachusetts RECEIVED
City/Town of NOV 3 0 2020
System Pumping Record
TOWN OF NURTHANDUVER
Form 4 HEALTH DEPARTMENT
DEP has provided this form for use--by local Boards of Health. Other forms may'beused,but the
information must be substantially the two as that provided here. Before using Ahis 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/ 'g t rear of housi , Left/right side of house, Left
Right side of building, Left/Right front of building, Le g ar of building, Under deck
Address . a
c4 rown State Zip Code
Z. System Owner.
Name.
Address(ir different from location)
CilylTown StaterC�� C.J Zip Code
f
Telephone Number
B. Pumping record
1. Date of Pumping Date 2 Quantity Pumped:
Gallons
3. Type-of system: ❑ Cesspool(s) eptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes Lslto If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System: v� co�
6. System Pumped By:
Neil.Batesbn F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Location where content&were disposed:
S Lowell Waste Water
SignAture qt HbulwuDate
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