HomeMy WebLinkAboutSeptic Pumping Slip - 22 TIFFANY LANE 9/26/2017Commonwealth of Massachusetts
City/Town of.
System Pumping. Record
Form 4
C I
SE...) 2 6 ?Oil
TOWN OF NORTH ANDO
• HEALTH DEPARTMENT
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 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
I. System Location: Left / Right front of house, Left/ Right rear of house, / right0i-of-troilse, /
Right side of building, Left / Right front of building, Left / Right rear of building, Under
Address
City/Town
2. System Owner:
6
C
State
Zip Code
Warne•
Address (if different from location)
City/Town •
State
Telephone Number
•B. Pumping Record
•
1. Date of Pumping Date 2. Quaptity Pumped:
Gallons
3. Type.of system 0 Cesspool(s) eptic Tank EI Tight Tank
Other (describe):
4. Effluent Tee Filter present? D Yes
" 5. Condition of Syst m:
If yes, was it cleaned? Q Yes 0 No,
6; System Pumped By:
Neil Batesbn
' Name
Bateson Enterprises Inc
Company
7. Locationwhere contents -were disposed:
Lowell Waste Water
F5821
Vehicle License Number
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