HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 177 CARLTON LANE 4/23/2020 RECEIVED
Commonwealth of Massachusetts qp� 21 zap
City/Town of
OF
S stem P-um in Record TOWN LT NORTH ANDUT
y p g HEALTH DEPARTMENT
Form 4
DEP has provided this form for use-by local Boards of Health. Other forms maybe bsed,but the
information must be substantially the two 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 AVigo tit side of hous Left/
Right side of building, Left/Right front of building, Left/Right rear of building, N er ec c
Address 1
c �
City/town State Zip Code
2. System Owner. f
Name
Address(if different from location)
CWrown 7Sta Zip
��a -`�6y L/ e
Telephone Number
B. Pumping Record
1-?
1. Date of Pumping Date 2. Quantity Pumped:
Gauons
3. Type-of system: ❑ cesspool(s) eptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes LSO If yes,was it cleaned? ❑ Yes ❑ No
5. Condition of Systq
6. System Pumped By:
Neil.Batesbn F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Location where contentewere disposed:
G L S Lowell Waste Water
Sign e l taui Date
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