HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 26 LONG PASTURE ROAD 7/8/2021 : Commonwealth of Massachusetts RECEIVED
City/Town of JUL 0 8 2021
System Pumping Record TOWN OF NORTHANDoVER
Form 4 HEALTH DEPARTMENT
DEP has provided this form for us&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: eft/� 'gh t of hou Left/Right rear of house, Left/right side of house, Left
Right side of build, , Left/ uildlhg, Left/Right rear of building, Under deck
Address
Cfty/rown l state Zip Code
2. System Owner.
Name
Address(if different from locafion)
C'tyiTown
Telephone Number
B. Pumping record
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? ❑ Yes o If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
6. System Pumped By:
Neil.Bateson F5821
Name Vehide License Number
Bateson Enterprises Inc
Company
7. Location where content were disposed:
_L S Lowell Waste Water
Signftfe qt Haul Date
t5form4.doa 06/03 System Pumping Record•Page 1 of 1