HomeMy WebLinkAbout- Septic Pumping Slip - 178 HAY MEADOW ROAD 1/7/2019 Commonwealth of Massachusetts RECEIVED
City[Town of
System Pumping Record
Form 4 TOW14 OF NORTH M0(WEIR
IIHEALTH .)U1N3,1 wii r
DEP has provided this form for use-by local Boards of Health. Other forms maybe*used,but the
Information-must be substantially the tame as that provided here. Before using.this form,check with your
local Board of Health to determine the forrh they use.The;System Pumping Record must be submitted to
the local Board of Health or other approving authority.
A. Facility In for Mation
1. System Location: (e;,,Alg rfk�iiQW�houss Left I Right rear of house, Left./right side of house, Left I
— W—0fit
Right side of building, Left/Right front of building, Left/Right rear of building, Under deck
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Address
E I n -
cityfrown state Zip Code
2. System Owner
Name'
Address(if different from location)
ciwrown Stater Zip Code
(/"���
Telephone Number
B. Pumpling K-ecord
1. Date of Pumping Date 2. (4,lucanlumped: Gallons
3. Type-of system: Cesspool(s) Eg-Sieptic Tank El Tight Tank
Other(describe):
4. Effluent Tee Filter present? E] Yes 0- If yes, was it cleaned? Yes ❑ No
5. Condition of System:
6. System Pumped By:
Neil.Batesbn F5821
Name Vehicle License Number
Bateson Enterprises Ina
Company
Location w 7. Loc..4contents-were disposed:
G,L S-P Lowell Waste Water
Sign a qt HauleiCT Date
tftrm4.dor,-08/03 System Pumping Record m Page 1 of 1