HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 434 BOXFORD STREET 8/10/2020 Commonwealth of Massachusetts RECEIVED
City/Town of AUG 10 2020
System Pumping Record
Form 4 TOWN OF NORTH AN� ��
HEALTH DEPARTMENT
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 forrh they use.The System Pumping Record must be submitted to
the local Board of Health or other approving authority.
A. Facility Information
1. System Locatio Legh nt of Left/Right rear of house, Left/right side of house, Left/
Right side of but? idin Left/ ront of building, Left/Right r� g, g, � t ear of building, Under deck
Address
C,FwTown State Zip Code
2. System Owner.
Name
Address(i different from location)
C4fTown state- 4�-,\
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped:
Gallons
3. Type-of system: ❑ Cesspool(s) 9'9 p c Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes LSO If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System: A_kl�d
v,%,k rca�,W
6. System Pumped By:
Neil.Batesbn F5821
Name Vehicle t_tcense Number
Bateson Enterprises Inc
Company
7. Locati ere contents-were disposed:
A L S Lowell Waste Water
Sign We 9t HaulwU Date
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