HomeMy WebLinkAboutSeptic Pumping Slip - 437 SALEM STREET 10/15/2015 Commonwealth of Massachusetts RECEIVED
City/Town of I 92,[W")
S Yitem Pumping.Record
S T OWN OF �JOFIJ H ANDOVER
Form 4 HEALTH DEpARTMENT
DEP has provided this form'for use=by local Boards of Health. Other forms maybe'used, b"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 hous a' >Righi,1�5-r"'of hpy so, Left/right side of house, Left
_r
W la
Right side of building, Left Right front of )Vui ?inhgg.`Left Rigffiriai of building, Under
Address
CitylTown State Zip Code
2. System Owner.
vl-�
Name'
Address(N different from location)
Cityrrown Stater Zip Code
->--61-
Telephone Number
B. Pumping R�cord
1. Date of Pumping 2. Quantity Pumped:
Date Gallons
3. Type•of system" ❑ Cesspool(s) [a,Siiipiic`Tank ❑ Tight Tank
[:1 Other(describe):
4. Effluent Tee Filter present.? ❑ Yep ❑,,.fi�o� If yes, was it cleaned? ❑ Yes F-1 No,
5. Condition of System:
\V, 2
6; System Pumped By:
Nell.Batesbn - F5821
Name Vehicle License Number
Bateson Enterprises Inc-
Company
7. Locat!q where contents-were disposed:
Lowell Waste Water
Sign itu Te cfl-laulev Date
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