HomeMy WebLinkAboutSeptic Pumping Slip - 35 TIFFANY LANE 8/15/2018 Commonwe.Althof Massachuseffs FM SEI VE
CWWTown of
SyMem Pumping.Record
TOWN OF NORTH ANDWER
Form 4
DEF has provided this fom i for useaby local Boards 'of Health. Other forms may be'used,but the
information-roust be substantially the tame as that provided here. Before using.this form,check with your
local Board of Health to determine the fcrrh they use. The System Pumping Record must be submitted to
the local Board of Health or other approving authority.
A. c114 . InforMation,
1, System Location: Left/ fi Pous , Left l Fight rear of house, Left/right side of house, Left
Bight side of building, Left/Right front of building, Left/Right rear of building, lender de'ck
Address —�
cityrrown State Zip Code t
1
2. System towner:
• Nano'
Address(if different from location)
citylTown ' Sta r ip e
'telephone Number
PuMpling Rpcord
1. Date of Pumping Date . �ubntity Pumped:
Galion
s
3. T e•of system.- r.
yp y. Cesspool(s) eptic Tank � Tight'Tank
Other(describe):
4. Effluent Tee Filter present? 0 Yes o If yes, was it cleaned? E3Yes El No,
' 5. Condition of.System: .
6., System Pumped By:
Pled.Meson F5821
Name Vehicle License Number
Bateson Enterprises Ina
Company
7. Lo ere contentawere disposed:
C Lowell Waste Water
{
Sign Houle Date 1
F
t5fbrm4.doc^06/03 System pumping Record•page 1 of 1