HomeMy WebLinkAboutseptic tank - Septic Pumping Slip - 52 NORTH CROSS ROAD 5/18/2020 : Commonwealth of Massachusetts RECEIVED
City/Town of
h. System Pumping Record MAY 18 2020
Form 4 TOWN OF NORTHANDU'v7 .
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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 house, Left/Rig rear of hous. ,Left/right side of house, Left
Right side of building, Left/Right front of building, Left/ g rear of building, Under deck
Address
OftyRown state Zip Code
2. System Owner.
Name'
Address(if different from location)
CiWTown State TM red
�3_ 3 C: f Y3
Telephone Number
.B. Pumping Record
1. Date of Pumping Date 2 Quantity Pumped:
Gallons
3. Type-of system: ❑ Cesspool(s) eptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes Ld"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. Location where contents-were disposed:
Lowell Waste Water
Sign acfHaulwUDate
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