HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 112 COLONIAL AVENUE 10/30/2019 : Commonwealth of Massachusetts RECEDED
City/Town of OCT 30 2019
System Pumping Record TOWN OF NORT H ANouvER
Form 4
DER has provided this form for use-.by local Boards of Health. Other forms may be but the
information must be substantiagy 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 Locatio�9 ron of hoes Left/Right rear of house, Left/right side of house, Left 1
Right side of building, Left/Rig ron o building, Left/Right rear of building, Under deck
Address p C
c4frown ` state Zip Code
2. System Owner.
Name" V�
Address(d different from location)
CWrown
Tetephone Number
B. Pumping record �c 4C� �
1. Date of Pumping Date 2- Q lily Pumped: Gauons
3. Type of system: ❑ Cesspool(s) ; eptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes 011No If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System: � � sz)
<�
6. System Pumped By:
Neil.Bateson F5821
Name Vehide Ucense Number
Bateson Enterprises Inc
Company
7. Lo RHaurlwU
contents were disposed:
G_ Lowell Waste Water
sign Data
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