HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 1659 OSGOOD STREET 4/1/2020 RECEIVED
Commonwealth of Massachusetts APR _ 12020
City/Town of TOWN OF NORTHA%l)t/St
System Pumping Record :SALT"°EPUFAT
Form 4
DEP has provided this form for usez 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/66h side of house, Left/
Right side of building, Left/Right front of building, Left/Right rear of building, Under deck
Address io-sq !J
City/Town State Zip Code
2. System Owner. �o e
Name
Address(if different from location) , nC%ice Vim- 'V
CityJTown ZkLCcde
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Type of system: ❑ Cesspool(s) eptic Tank ❑ Tight Tank
❑ Other(describe):
i
4. Effluent Tee Filter present? ❑ Yes Q No If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of Syste j V �
6. System Pumped By:
Neil.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Locationwhere contents were disposed:
Lowell Waste Water
Sign a ct HauleU Date
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