HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 75 HAY MEADOW ROAD 11/19/2019 Commonwealth of Massachusetts RECEIVED
City/Town of NOV 19 2010
AN
System Pumping Record TOWN,CF NORIH
I.THDEPARTMENT R
Form 4 H
DER has provided this form for use=by local Boards of Health. Other forms may beused, 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:(�eft Ri front of house eft/Right rear of house, Left/right side of house, Left/
Right side of buildlt M, Left f building, Left/Right rear of building, Under deck
Address -
cFdy-1 own State Zip Code
2. System Owner.
Name
Address(if different from location)
Cityrrown State 1p Code
�0
-�a-�
Telephone Number
B. Pumping Record
1. Date of Pumping Date ;2. Quan ' Pumped:
Gallons
3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes o If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of Syst m•
6. System Pumped By:
Neil.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc-
Company
7. Locati era 4ontents were disposed:
G L S Lowell Waste Water
Sign We cfHauf Date
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