HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 83 LOST POND LANE 6/14/2021 Commonwealth of Massachusetts RECEIVED
• City/Town of JUN 14 2021
System Pumping Record
Form 4 TOWN OF NOR7HANWVER
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.fhis 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 i WMO—nt of h house,Left/Right rear of house, Left/right side of house, Left/
Right side of building, Left/Right ron onuilding, Left/Right rear of building, Under deck
AddressL-C-
Wf own State Zip Code
2. System Owner.
Name
Address(if different from location)
CitylTown Stat��C v Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Type of system: ❑ Cesspooks) eptic Tank ❑ Tight Tank
❑ Other(describe): /
4. Effluent Tee Filter present? ❑ Yes Ej'14o 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. Location a contents were disposed:
_L S Lowell Waste Water
Sign We 9t HauleV Date
t5form4.doa 06/03 System Pumping Record•Page 1 of 1