HomeMy WebLinkAboutSeptic Pumping Slip - 29 WHITE BIRCH LANE 9/26/2017Commonwealth of Massachusetts
s 2
City/Town of . 6 Z01
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 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, Left /ight Left / right side of house, Left /
Right side of building, Left / Right faint of building, LTft / Right rear cif building, Under deck
Address
2. System Owner
Name'
?0,1A0Li t (
State Zip Code
Address (if different from location)
City/Town
State
TeIeph6ne
g
umber
I 7
Zip Code
B. Pumping Record
1 Date of Pumping
3. Type -of system': Ej
0 Other (describe):
Date
I"1
entity Pumped:
TOWN OF NORTH ANDO
HEALTH DEPARTMENT
Gallons
Cesspool(s) L Septic Tank 0 Tight Tank
X4. Effluent Tee Filter present? 0 Ye.s No
' 6. Condition ofSystem:
6: System Pumped By:
Neil Bateson
Name
Bateson Enterprises Inc
Company
7. Locationiielere contentswere disposed:
Lowell Waste Water
If yes, was it cleaned? EI Yes El No,
F5821
Vehicle License Number
F
Sign Haul
D te
t5form4.doc• 06/03 System Pumping Record • Page 1 of 1