HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 693 JOHNSON STREET 4/28/2021 ..C�x Commonwealth of Massachusetts E�ZE E IL�rZEED
City/Town of APR 2 8 2021
System Pumping Record rOWN OF NURTHANDUVER
Form 4 HEALTH GEPARIMENT
DEf has provided this form for umby 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
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/Right rear of house, Left/right side of house, Left 1
Right side of building, Left/Right front of building, Left/Right rear of building, Under deck
Address C�
City/Town State Zip Code
2. System Owner. HO
Name
Address Of different from location)
CitylTown State r G �t n��—Code
Telephone Number `C
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped:
Gallons
3. Type-of system: ❑ Cesspool(s) 56ptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? es ❑ No If yes, was it cleaned? ❑ No
5. Condition of stem: A,�-e-
6. system Pumped By:
Neil.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Location a contentarwere disposed:
G L S Lowell Waste Water
Sign We qt HaiFwV Date
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