HomeMy WebLinkAboutSeptic Pumping Slip - 434 BOXFORD STREET 7/31/2017Cornmonwe Ith of Massachusetts
Citij/Town of .
System Pumping_ Record
Form 4
•
DEP has provided this form' for use:by local Boards Of Health. Other formS may be used, but the
informationmust 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 ystern Pumping Record must be submitted to
the local Board of Health or other approving authority.
JUL3 2011
TOWN OF NORTH ANDO
HEALTH DEPARTMENT
A. Facility Information
1 System LocationcLO/ Rig front of ho e?Left/ Right rear of house, Left/ right side of house, Left /
Right side of building, Left / Rigfr�bt of building, Left / Right rear of building, Under deck
Address
J)
City/Town State Zip Code
2. System Owner:
Name'
1 \ 0 ( a (4•A
Address (if different from location)
City/Town
State Zip Code
‘, 0
Telephotfe• Number
B. Pumping Record
(
1. Date of Pumping ?
Date 2 Quantity Pumped: Gallons
3. Type -of system'. El Cesspool(s) Egeptic Tank 0 Tight Tank
0 Other (describe):
4. Effluent Tee Filter present? 0 Yes No If yes, was it cleaned? 0 Yes 0 No,
" 5. Condition of System:
6: System Pumped By:
Neil. Bateson •
• Name
Bateson Enterprises Inc
Company
7. Localion-whe
G.LS.
Sign Hauls
c
F5821
Vehicle License Number
oivvk
ntents were disposed:
Lowell Waste Water
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