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HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 230 GRAY STREET 6/14/2021 Commonwealth of Massachusetts RECEIVED City/Town of System Pumping Record TOWN OF HURT H ANDUVER Form 4 W TH 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/Right front of housedeiP�igfkrP f how , Left/right side of house, Left Right side of building, Left/Right front of building, Left/Right rear of building, Under deck Address Ciiy/Town State Zip Code 2. System Owner. p � Name Address(if different from location) City/Town Sta a Zi Telephone Number B. Pumping record 1. Date of Pumping Date 2. Quantity Pumped: canons 3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Other(describe): 4. Effluent Tee Filter present? ❑ Yes 0'N0 If yes, was it cleaned? ❑ Yes ❑ No 5. Condition of System: 6. System Pumped By: Neil.Bate-son F5821 Name Vehicle License Number Bateson Enterprises Inc Company 7. Locatio he contents-were disposed: G L Aul Lowell Waste Water Sign ev Date t5f6rm4.doc•06/03 System Pumping Record•Page 1 of 1