HomeMy WebLinkAboutSeptic Pumping Slip - 100 CRICKET LANE 9/12/2017Commonwealth of Massachusetts
City/Town of
System Pumping. Record
Form 4 TOWN OF NORTH AN
HEALTH DEPARTMENT
SEP
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 forrn, 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 Locatio Rigi rat;fhouse Left/ Right rear of house, Left / right side of house, Left /
Right side of buil ng, Left / Rig t front of builclirig, Left / Right rear of building, Under deck
Address
00
City/Town
2. System Owner:
J.
State Zip Code
Na
Address (if different from local(on)
City/Town
State Zip Code
Telephone Number
n
B. Pumping Record
1. Date of Pumping Quantity Pumped:
Date Gallons
3. Type -of system': Ej Cesspool(s) Septic Tank 0 Tight Tank
Ej Other (describe):
4. Effluent Tee Filter present? 0 Yes No If yes, was it cleaned? El Yes El Na
' 5. Condition of System:
System Pumped By:
Neil Batesbn
Name
Bateson Enterprises Inc
Company
7. Lpoation- here contents were disposed:
F5821
Vehicle License Number
Lowell Waste Water
Sign Date
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