HomeMy WebLinkAboutSeptic Pumping Slip - 41 CEDAR LANE 9/26/2017Commonwealth of Massachusetts
City/Town of
System Pumping. Record
Form 4
? 6.7011
TOWN OF NORTH ANDO
HEALTH DEPARTMENT
DEP has provided this form for useoby 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-t Right rear-of_h_ouse Left/ right side of house, Left /
Right side of building, Left / Right front of building, Left / Right rear of building, Under deck
Add
s c.
•
City/Town
2, System Owner:
State
Zip Code
Name*
Address (if different from location)
CityiTown
A
Stat
c, Zip de
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2. Quefijily Pumped:
Gallons
3. Type.of system': El Cesspool(s) El-t‘tic Tank 0 Tight Tank
0 Other (describe):
4. Effluent Tee Filter present? 0 Yep
' 5. Condition of §'fsterri:
If yes, was it cleaned? EI Yes 0 No,
(
6: System Pumped By:
Neil. Bateson
' Name
Bateson Enterprises Inc
Company
7. Location er- •ontents were disposed:
Lowell Waste Water
F5821
Vehicle License Number
Signt e. HauteDate
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