HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 205 GRAY STREET 11/19/2019 RECEIVED
Commonwealth of Massachusetts NOV 19 2Pq
City/Town of TOWN OF NORTHANUOVER
System Pumping Record HEALTH DEPARTMENT
Form 4
DEP 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:Cefft Righ ron of house eft/Right rear of house, Left/right side of house, Left 1
Right side of building, Left/Right front of building, Left/Right rear of building, Under deck
Address
do y-e-(
C'Wrown state Zip Code
2. System Owner.
Name
Address(d different from location)
City/Town state Zip Code
Telephone-Number
B. Pumping Record
1. Date of Pumping i t . a ' uantity Pumped:
Date Gallons
3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes 0. No If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System: / 1-e-Q
rwt �l -r: l
6. System Pumped By:
Neil.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc-
Company
7. Locative-v ere contents were disposed:
G L Lowell Waste Water
Signhwfe ctHaul Date
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