HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 520 BOSTON STREET 2/24/2020 : Commonwealth of Massachusetts RECEIVED
City/Town of FEB 2 4 2020
System Pumping Record
Form 4 TOWN OF NOR H ANLWER
uGr Tu nEPARTMEPST
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 hous<i;�Rig rea o weft/right side of house, Left
Right side of building, Left/Right front of building, Left/Right rear of building, Under deck
Address ` ae-
CftyRom State Zip Code
2. System Owner: PC)b_9_4�
Name'
Address(if different from location)
CitylTown State
Telephone Number
B. Pumping Record /
1. Date of Pumping Date 2. Quantity Pumped: dons
3. Type-of system: ❑ Cesspool(s) eptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of/ Eit
6. System Pumped By:
Neil.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Locatioambere contents were disposed:
G L.S. Lowell Waste Water
Sign a Haul Date
t51brm4.doa 06/03
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