HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 31 VEST WAY 11/2/2021 : Commonwealth of Massachusetts RECEIVED
City/Town of
System Pumping Record TOWN CFNORTHAWOVER
Form 4 HEALTH DEPARTMENT
DEP has provided this form for use by local Boards of Health. Other forms may be Lsed, 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, g arbf hou e, Left/right side of house, Left
Right side of building, Left/Right front of bue of building, Under deck
Address S
City/Town �J State Zip Code
2. System Owner. /� ,
Name
Address(if different from location)
CityJTown State l � �8t0 de
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 1z, If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:�s 1,
6. System Pumped By:
Neil.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Locatio re contents-were disposed:
L S Lowell Waste Water
ems—aid--C
Signitule cri-iauleV Date
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