HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 62 FARNUM STREET 5/17/2021 : Commonwealth of Massachusetts RECEIVED
City/Town of MAY 17 7021
System Pumping Record TOWN OF NORTHANDOVER
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 0jifront 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 �'
city/rown State Zip Code
2. System Owner.
Name' Uv t
Address(if different from location)
cityrrown State &?—5 3 code
Telephone Number
B. Pwnping record E-L a
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? es ❑ No If yes, was it cleaned? Lames LJ No
5. Condition of Syst
6. System Pumped By.-
Nell.Bateson F5821
Name Vehicte License Number
Bateson Enterprises Ina
Company
7. Locati re contents,were disposed:
G L S Lowell Waste Water
�^ ra
sign,ftle Cf Hbulev Date
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