HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 427 SUMMER STREET 4/1/2020 Commonwealth of Massachusetts RE�EIVE>fl
_ City/Town of
System Pumping Record APR _ 12020
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Form 4 TOWN O NORTH ANUUv
J,cNT
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,Pinftgal,
gt>�r 'a_ of ho Left/right side of house, LeftRight side of building, Left/Right front of buift/Right rear of building, Under deck
Address
Cltyrrown _ state � \ Zip Code
2. System Owner. �z ,
Name
Address(if different from location)
CiWown State
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):
4. Effluent Tee Filter present? ❑ Yes allo If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of Sy to .:
-
6. System Pumped By:
Neil.Bateson F5821
Name Vehicle Lrcense Number
Bateson Enterprises Inc
Company
7. L ' contents,were disposed:
7L S. Lowell Waste Water
14�. Hk
Signitufe Haul Date
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