HomeMy WebLinkAboutseptic tank - Septic Pumping Slip - 137 CHRISTIAN WAY 6/2/2021 : Commonwealth of Massachusetts RECEIVED
City/Town of Jot 0 2 NZ,
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
iocal Board of Health to determine the forrh they use.The System Pumping Record must be submitted to
the local Board of Health or other approving authority.
A. Facility Information
1. System Locatio . Righ fro \of fiou , Left/Right rear of house, Left/right side of house, Left/
Right side of building, Left/Rigttit ron of building, Left/Right rear of building, Under deck
Address � � 7
City/Town State Zip Cotle
2. System Owner. f� ).+c,
Name'
Address(if different from location)
CWTown Stater Tip Code
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Type-of system: ❑ Cesspool(s) 0-80ba Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes a'MO 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. Locqfi'owWhere contents-were disposed:
G L S Lowell Waste Water
Sign a Haul Date
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