HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 305 ABBOTT STREET 5/18/2020 RECEIVED
: Commonwealth of Massachusetts MAY 1 8 2020
City/Town of
System Pumping Record TOWN NORTH R
Y p g HEALTH DEPARTMENT
Form 4
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
focal 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 ht ront�hou eft/Right rear of house, Left/right side of house, Left
Right side of building, Left/Rig ront of building, Left/Right rear of building, Under deck
Address `�
City/Town State Zip Code
2. System Owner. ..—� t ,�
l r Y C�
Name.
Address(i different from locafton)
Cityrrown stag zi Coi�
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped:
Gallons
3. Type-of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes D No if yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
6. System Pumped By:
Neil.Batesbr► F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. LocatioiLwhere contents-were disposed:
js�iqn
S Lowell Waste Water
OA.
Haul Date
t51brm 4.dm-OS103 System Pumping Record•Page 1 of 1