HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 1538 TURNPIKE STREET 7/1/2020 RECEIVED
:-C\ Commonwealth of Massachusetts JUL 01 2020
City/Town of TOWN OF NORTH ANDWER
System Pumping Record HEALTH DEPARTMENT
Form 4
DEf has provided this form for use-by local Boards of Health. Other forms maybe'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/Ri ht_front of house Left/Right rear of house, Left/right side of house, Left
Right side of bul7din , / rout o uildiAg, Left/Right rear of building, Under deck
,dress
Clty/To" `�— State Zip Code
2. System Owner.
Name'
Address(if different from location) t�(�, t^ �
CWrown State Zi Code
Telephone Number
B. Pumping Record
1. Date of Pumping Bate 2. Quantity Pumped:
Gallons
3. Type-of system: ❑ Cesspool(s) ptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes Lam'No If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System: Q ��
6. System Pumped By:
Neil.Batesbn F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Location a contents were disposed:
ULSQ Lowell Waste Water
Signitufe cfHaulwUDate
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