HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 211 CANDLESTICK ROAD 8/20/2019 :4 Commonwealth of Massachusetts RECEIVED
City/Town of AUG 2 0 2019
System Pumping Record
TOWN OF NORTH ANUUVER
Form 4 HEALTH DEPARTMENT
DEP has provided this form for use=by 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 form they use.The System Pumping Record must be submitted to
the local Board of Health or other approving authority.
A. Facility Information
1. System Location: Left/Right front of house, Le 1 rear of hoy , Left/right side of house, Left
Right side of building, Left/Right front of building, Left/Righ rear of building, Under deck
Address
Citylrown ` State Zip Code
2. System Owner. � � t �
Name"
Address(if different from location)
CitylTown Stat�S� i6ejp� �
Telephone Number
B. Pumping Record
1. Date of Pumping 2. Quantity Pumped:
Dam Gallons
3. Type-of system: ❑ Cesspool(s) piic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes o If yes,was it cleaned? ❑ Yes ❑ No
5. Condition of System: �� ��l,�.l:�t� �✓��� � I�
S. System Pumped By:
Neil.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Ina
Company
7. Lo he a contents-were disposed:
rG S y Lowell Waste Water
qK a- A. _c3 _N
Sign aqtHbulW Date
t5form4.doc•06/03 System Pumping Record•Page 1 of 1