HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 225 HAY MEADOW ROAD 8/9/2019 Commonwealth of Massachusetts p CEI
VED
City/Town of
System Pumping Record auG Q a
Form 4 TOWN OF NORTH AWOVER
HEALTH DEPARTMENT
DEP has provided this form for umby local Boards of-Health. Other forms may be used,but the
information,must be substantially the same as that provided here. Before using.this form,check with your
local Board of Health to determine the foram they use.The System Pumping Record must be submitted to
the local Board of Health or other approving authority.
A. FacHity Information �r
1. System Location: Left/Right front of housexj�gh reV-Wff
house Left/right side of house, Left
Right side of building, Left/Right front of building, Left/ l o build'mg, Under deck
Address
CKylrown State �./ Zip Code
2. System Owner.
Name
Address(if different from location)
Citylrown Stater < Z
Telephone Number
.B. Pumping K-ecord V1
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Type-of system: ❑ Cesspool(s) eptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes L y'No If yes, was it cleaned? ❑- Yes ❑ No,
5. Condition of System:
6. System Pumped By:
Neil.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Lo ' n where contents-were disposed:
L S Lowell Waste Water
I
Sign We cf Hbul Date
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