HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 124 STONECLEAVE ROAD 8/10/2020 Commonwealth of Massachusetts RECEIVED
City/Town of AUG 10 2020
TOWN OF NORTH�D System Pumping Record HEALTH DEPARMaIT
Form 4
DEP 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 hous%f lg rear of h�dif
Left/right side of house, Left/
Right side of building, Left/Right front of building, Left/Rig rear building, Under deck
Address � �� ��a /7
MWrown State Zip Code
2. System Owner.
Name'
Address(ir different from location)
CWTown state Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping Bate 2. Quantity Pumped:
Gallons
3. Type of system: ❑ Cesspool(s) lc Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes Leo 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. Loc4tiorrwhpre contentsrwere disposed:
AS-P Lowell Waste Waters Date
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