HomeMy WebLinkAboutSewer Lift Station - Septic Pumping Slip - 465 CHESTNUT STREET 5/18/2020 .A\- Commonwealth of Massachusetts RECEIVED
Clty/Town of
System Pumping Record MAY 18 2020
Form 4 TOWN OF NORTH AN FUVER
�p T,N CEPARTi _!�T
DEP has provided this form for use=by local Boards of Health.Other forms may *used, but the
information must be substantiagy 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 hou / <rea;roKh , Left/right side of house, LeftRight side of bul7ding, Left/Right front of bul ing, Lerear of build'mg, Under deck
Address
City/Town State Zip Code
2. System Owner.
Name"
Address(if different from location)
CitylTown State � ? �'l� Trp Code
Telephone Number
B. Pumping Record
,L4 ate,
1. Date of Pumping Dal 2. Quantity Pumped:
Gallons
3. Type-of system: ❑ Cesspool(s) ❑ Septic Tank I Tight Tank
5ther(describe):
4. Effluent Tee Filter present? ❑ Yes ❑ No 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 �arl3er contents were disposed:
G L Lowell Waste Water
laA.
Sign a Haul Date
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