HomeMy WebLinkAboutSeptic Pumping Slip - 10 STILES STREET 8/10/2016 uwM'ww.m YIMSIL(dllWltlYpIWW'�IYV&IW%i//nJIf4WMMNiiIIMrc@hbtiN
Commonwealth of Massachusetts RECEIVED
x City/Town of
- System Pumping Record
Form 4 TOWN OF NOW H AN
HEAL111 D PA R 7j'! E r
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 side of house ight side of hou e,Left front of house, Right front of house,
Left rear of house, Right rear of house. eft rear of building. Right rear of building.
_..__.-----------
_
Address
Cityrrown State Zip Code
2. System Owner:
t
Name
Address(if different from location)
_�._. _.._._.._.-.------
--
CitylTown State Zip Code
Iglel _
Telephone Number
B. Pumping Record -
1. Date of Pumping — --' -r� 2. antity Pumped: ___-----
Date Gallons
3. Type of system: El Cesspool(s) 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. Locatio re contents were disposed:
.L D Lowell Waste Water
g to a of Haul r Date
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