HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 99 PHEASANT BROOK ROAD 5/24/2021 Commonwealth of Massachusettsqi RECEIVED
of
System Pumping Record MAY 2 4 7.021
Form 4 TOWN OF NORi H ANDOVER
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.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 side of house, Left/
Right side of building, Left/Right front of building, Left/Right rear of building, Under _
Address P4-t& aksi-
Citylrown State Zip Code
2. System Owner.
Name'
Address(if different from location)
CWrown Sty Zi Code
Telephone Number
B. Pumping Record
5--
I. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Type-of system: ❑ Cesspool(s) c Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes E,_fild' If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of Sy tem�
6. System Pumped By:
Neil.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Location where contents-were disposed:
C.L S Lowell Waste Water
SigniWe it Haul Date
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