HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 826 JOHNSON STREET 10/30/2019 Commonwealth of Massachusetts RECEIVED
_ City/Town of OCT 3 0 2019
System Pumping Record TOWN OF NORTHANtER
Form 4 HEALTH DEPARTMEW
DEP has provided this form for use=by local Boards of Health. Other forms may be bsed, 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, Left/Right rear of house,�Leftg side off house-Left/
Right side of building, Left/Right front of building, Left/Right rear of building, Under deck
Address _
CiWTown State Zip Code
2: System Owner.
Name* v 1
Address(if different from location)
City/Town
Telephone Number
B. Pumping Record
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 ❑'No If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
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
Sign a Haul Date
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