HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 166 REA STREET 3/2/2020 RECEIVED
: Commonwealth of Massachusetts
• City/Town of MAR C ? 2020
System Pumping Record TOWN NORTH R
Form 4 HEALTT H DEPARTTMENTMENT
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 forrh 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 rear of hogs .Left/right side of house, Left/
Right side of building, Left/Right front of building, Left/Righ rear of building, Under deck
Address Pe 01�_
city/rown state Zip Code
2. System Owner.
Name"
Address(if different from location)
City/Town state6 a —ClE�4Y M 7`a
Telephone Number — /
B. Pumping Record
1. Date of Pumping 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 1 �S i_�j
6. System Pumped By:
Neil.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Location contents-were disposed:
_L S Lowell Waste Water
Signftfe qj HaulerU Date
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