HomeMy WebLinkAboutseptic tank - Septic Pumping Slip - 11 BRIDGES LANE 11/26/2019 Commonwealth of Massachusetts RECEIVE®
City/Town of �a19
System Pumping Record Nov 26
Form 4 ,�� !pF NORTH ANDU�ER
DEPARTMENT
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: Left/Right front of house, Left/l�lg rtrt earhouse,- eft/right side of house, Left
Right side of building, Left/Right front of building, Left/Righ rear of building, Under deck
Address
City/Town ( state Zip code
2. System Owner.
Name
Address(f different from location)
CityiTown State Zip Code
Telephone Number
B. Pumping Record p
1. Date of Pumping
p g Date 2. Quantity Pumped: Gallons
3. Type of system: ❑ Cesspool(s) [}-Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes ❑ No If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
6. System Pumped By:
Neil.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc-
Company
7. Location where contents were disposed:
(31 S Lowell Waste Water
-wa I
Sign a �A-
9t HauleU Date
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