HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 10 CAMPBELL ROAD 8/4/2021 Y Commonwealth of Massachusetts RECEIVED
City/Town of iu ; 0 4 ?0 2 i
System Pumping Record
Form 4 TOWN OF NORT H ANDOVER
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
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,� ft/Yig sid od f house�Left
Right side of building, Left/Right front of building, Left/Right rear of building, Un er ec
Address
Cityrrown !v state Zip Code
2. System Owner.
Name c'
Address(if different from location)
Cityirown Statgg'''',) 17 Idp
j
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Type of system: ❑ Cesspool(s) Ea--Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes No 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 where contents-were disposed:
.L S. Lowell Waste Water
Sign a Haul Date
t5form4.doa 06/03 System Pumping Record•Page 1 of 1