HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 75 HAY MEADOW ROAD 11/30/2020 Commonwealth of Massachusetts RECEIVED
City/Town of NOV 3 0 2020
System Pumping Record TOWN OFNORTHANDOVER
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/right side of house, Left
Right side of building, Left/Right front of building, Left/Right rear of building, Under deck
Address — p
CitylTown l state Zip Code
2: System Owner.
Name
Address(if different from location)
citynown Statue Zip} e
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 D_14�0 If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System: "'.�r VD� l,� J✓ �' ti 1il` �
6. System Pumped By:
Neil.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc-
Company
7. Lo wtere contents-were disposed:
7SG_L� . Lowell Waste Water
`( - f
SignAtufe 9t Htiuletj Date
,5form4.dora 06/03 System Pumping Record•Page 1 of 1