HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 105 CARLTON LANE 7/1/2020 RECEIVED
..- Commonwealth of Massachusetts JUL 0 ► 2020
City/Town of TOWN OF NORTH AN
System Pumping Record DEMRTUBMT
Form 4
DEf has provided this form for use by local Boards of Health. Other forms may *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 / ig �ofhousqLeft/right side of house, LeftRight side of building, Left/Right front of bui frig, Leftuilding, Under deck
Address �jC
CRY/Town State Zip Code
2. System Owner. C
Name'
Address(if different from location)
CiWown Ste• Zi _
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2. Qua "'Pumped: Gallons
3. Type-of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes M1, o 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. Locationcontents were disposed:
L S Lowell Waste Water
Wftgn Date
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