HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 121 OLD CART WAY 7/22/2020 :�L\ Commonwealth of Massachusetts
City/Town of RECEIVED
System Pumping Record JUL 2 2 202O
Form 4
TOWN OF NORTH HEEALLTH DEPARTMENT R
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: Le fight front of house ft/Right rear of house, Left/right side of house, Left
Right side of bulding, lg ron o uildirig, Left/Right rear of building, Under deck
Address
V
City/Town Sta Zip Code
2. System Owner.
Name
Address(if different from location)
CitylTown State Zi Code
Telephone Number `T
6. Pumping record
1. Date of Pumping Haile 2. Quantity Pumped:
Gallons
3. Type-of system: ❑ Cesspool(s) eptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System: VL
6. System Pumped By:
Neil.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Ina
Company
7. Locati h e contents-were disposed:
G L S Lowell Waste Water
on a Haul Date
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