HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 211 CANDLESTICK ROAD 8/16/2021 Commonwealth of Massachusetts RECEIVED
City/Town of AUG 16 2021
System Pumping Record TOM 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
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/�iqehouse, Left/right side of house, Left/
Right side of building, Left/Right front of building, Left/MJR-rear of building, Under deck
Address
CiWrown state Zip Code
2. System Owner I
Name
Address(if different from location)
City/Town State.q
Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped: Gallons
s
3. Type of system, ❑ Cesspool(s) [a Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System: l f ,i f,,V`Aa t
�
6. System Pumped By:
Neil Bates-on F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Locates where contents were disposed:
G L S Q Lowell Waste Water
-tea
Sign a Haul pate
t5form4.doc-06/03 System Pumping Record•Page 1 of 1