HomeMy WebLinkAboutSeptic Pumping Slip - 85 SULLIVAN STREET 8/15/2018 Commonwealth f Massachuseffs
Cit�/Town ofu
SyMem Pumping. TOWN OF NORTHANDVV
ER
Form 4 HEM iH MIARTMENT
DEP has provided this form for us&by local Boards of Health. Other forms maybe*used,but the
information'must be substantially the same as that provided here. Before using.this form,check with your
local hoard of Health to determine the forth they use. The System Pumping Record must be submitted f®
the local Board of Health or other approving authority.
A. Facility Inf®rr'sition
1. System Location: Left/Right front of house, Left/Right rear of hous Le . rig a u; Left/
Right side of building, Left 1 Right front of building, Left I Right rear of building, l)n er deck
Address
Cityfrown Mate dip Code
2'. System Owner.
"
Address(if different from location)
CikyJ7'own state,
Telephone Number '
i
Pumpling Ripcord
1. Cate of pumping Date ;��epfic
ty pumped: Gallons a�"
3. Type of system: Cesspool(s) Tank Tight Tank ,.
❑ Other(describe):
4.. Effluent Tee Filter present? ® Ye [g-tQo If yes, was it Cleaned? El Yes ® leo,
5. Condition of System:
6: System Pumped By:
Neil.Satesbbq F5621
Name Vehicle License Number
Bateson �hterprises Inc'
Company
ISIgn
re contents-were disposed:
: Lowell Waste Water
Houle Cam
t5form4.doc•06/03 System humping Record m page 1 of 1