HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 719 JOHNSON STREET 4/30/2020 : Commonwealth of Massachusetts RECEIVED
City/Town of APR 3 0 MAI
System Pumping Record
Form 4 TOWN OF NORTH ANUUVER
HEALTH DEPARTMENT
DEf 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, Left/Right rear of house, Left/dIdEside of hou , Left
Right side of building, Left/Right front of building, Left/Right rear of building, Under deck
Address tY(5� ace
Myfrom State Zip Code
2. System Owner.
Name'
Address(r different from location)
Chown Statr; Zi Code
Telephone Number
B. Pumping Record
1. Date of Pumping pate 2. Quantity Pumped: Gallons
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 System:
6. System Pumped By:
Neil.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Location where contents,were disposed:
_L S Lowell Waste Water
Sign aqtHikulWDate
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