HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 1116 SALEM STREET 9/22/2021 :&\- Commonwealth of Massachusetts RECEIVED
City/Town of SEP 2 2 ?.01
System Pumping Record TOwNOFNORTHANDOVER
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 autho ft.
A. Facility Information
1. System Location: Left/Right front of house ghtZ.�rof hous ' Left/right side of house, Left/
Right side of building, Left/Right front of bw di�eft/ rear of building, Under deck
Address ( I ( 6 �
City/Town State Zip Code
2: System Owner.
Name'
Address(if different from location)
City/Town State —� _ 3 e Z
Telephone Number
B. Pumping record
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Type of system: ❑ Cesspool(s) 0- ti Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes to If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System: C
6. System Pumped By.
Neil.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Ina
Company
7. Locatio here contents were disposed:
G L S Lowell Waste Water
Sign a Iieut Date
tftrm4.doc•06/03 System Pumping Record•Page 1 of 1