HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 27 BRADFORD STREET 9/9/2019 : Commonwealth of Massachusetts RECEIVED
City/Town of
System Pumping Record lows OF NORTH ANOUVER
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 house6 igh ear o hous , Left/right side of house, Left,/
Right side of building, Left/Right front of building, Left/Right rear of building, Under deck
Address
it�l
Cityfro+wn State Zip Code
2. System Owner.
Name"
Address V different from location)Cityfr
own state'-, ��� -Zip CQ98I t 7
hone Number
C
B. Pumping Record
1. Date of Pumping 2. Quantity Pumped:Date p Gallons
3. Type of system: ❑ Cesspool(s) eptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes Ulwo If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of stec), f�C�
6. System Pumped By:
Neil.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Location Where contents-were disposed:
G L S Lowell waste Water i
L-14MO- A.
Signk4a Haut Date
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