HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 218 LACY STREET 3/16/2020 Commonwealth of Massachusetts RECEIVED
_ City/Town of
System Pumping Record MAR 16 202►J
Form 4 TOWN OF NOR TH,N(UyER
�•• HEALTH DEPART`` - _.
DEP has provided this form for use=by local Boards of Health. Other forms may *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 Locati;4eiff font of hous eft/Right rear of house, Left/right side of house, Left
Right side of b , Left ront of building, Left/Right rear of building, Under deck
Address
Citylrown State Zip Code
2. System Owner.
Name
Address(if different from location)
Citylrown State c (- C) i ¢
Telephone Number CJ
B. Pumping Record
=z`
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Type of system: ❑ Cesspool(s) a-Septic Tank ❑ Tight Tank
❑ Other(describe): /
4,. Effluent Tee Filter present? ❑ Yes D N If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
6. System Pumped By:
Neil.Bates-on F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Location_where contents-were disposed:
Lowell Waste Water
Sign 4S.
aui Date
t5form4.doa 06/03 System Pumping Record•Page 1 of 1