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HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 49 ORCHARD HILL ROAD 12/23/2019 .-C-\ Commonwealth of Massachusetts RECEIVED _ City/Town of DEC 2 3 2019 System Pumping Record Too OF NORTHAN10VEP Form 4 HEALTH DEPARTMENT DEP has provided this form for use=by local Boards of Health. Other forms may be'used,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, Left/right side of house, Left 1 Right side of building, Left/(Rigflt rout-qTb—uiTd5n , Left/Right rear of building, Under deck Address City/Town State Zip Code 2. System Owner. Name Address(if different from location) CiWown State Zip Code Telephone Number B. Pumping record 1. Date of Pumping Date _ 1 2. Quantity Pumped: Gallons 3. Type of system: ❑ Cesspool(s) [y` 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. Locatipnvhqre contents were disposed: G L'; Lowell Waste Water Sign a Haul Date tftrm4.doc-06/03 System Pumping Record•Page 1 of 1