HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 32 CRICKET LANE 12/7/2020 RECEIVED
: Commonwealth of Massachusetts
City/Town of DEC 0 7 2020
System Pumping Record TOWN OF NORTHANDOVER
HEALTH DEPARTMW
Form 4
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 douse, Left 1 ' ht, ar of how, Left/right side of house, Left
Right side of building, Left/Right front of building, Left/ g—hT—rear of building, Under deck
Address d, C'k ` c—
City/rown ��► °° State Zip Code
2. System Owner.
Name
Address(if different from location)
WTaNm stair+
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 fro 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. Lon.L...
h*re contents-were disposed:
Lowell Waste Water
Sign We qt Haut Date
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