HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 74 COLONIAL AVENUE 4/30/2020 ..�Qx Commonwealth of Massachusetts RECEIVED
City/Town of APR 3 0 2020
System Pumping Record
TOWN OF NORTH
ER
Form 4 HEALTH DEPARTMENT
r•
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 houseAeft/Right rear of house, Left/right side of house, Left
Right side of building, Le ig ron o buildirg, Left/Right rear of building, Under deck
Address
Cityrrown State Zip Code
2. System Owner.
Name
Address(if different from location)
Cityfrown Ste pe
Telephone Number(
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Type of system: ❑ Cesspool(s) ER-Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes la-140 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. Lo where contents-were disposed:
G L ka
Lowell Waste Water �y
Sign Date
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