HomeMy WebLinkAbout- Septic Pumping Slip - 129 CHRISTIAN WAY 10/31/2018 Commonwealth of Massachusetts
City/Town of J'OWN Of-'NOR�H A�O(MER
System Pum 0 ping Record o,j,�J,�:l i DEW,RI MENT
Fonn 4
DEP has provided this form for use-by local Boards of Health. Other forms maybe'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 forth they use. The System Pumping Record must be submitted to
the local Board of Health or other approving authority.
A. Factlity InforMation
1. System Locatio ig Far-0--n—to Left Right rear of house, Left/right side of house, Left
I on
Right side of boil �ag, Left i�n�hooufsbuiildifig, Left/Right rear of building, Under deck
ITIgaTro
Address
\3q
cityfrown state Zip Code
2. System Owner
Name'
Address(if differentlocation)
cityfrown state- Zip Code
Telephone Number
,B. Pumping Record
1. Date of Pumping 2. Quantity Pumped:
Date Gallons
3. Type-of system: E] Cesspool(s) ff-Septic Tank El Tight Tank
El Other(describe):
4. Effluent Tee Filter present? yes If yes, was it cleaned? E31-'re-s�[] No
6. Condition of System:
6, System Pumped By:
Nell.Bates7on F5821
Name Vehicle License Number
Bateson Enterprises Ina
Company
7. Lo tion-w Fe ontents were disposed:
(� G S. Lowell Waste Water
sign a S.
Late
—�
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