HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 73 FOREST STREET 8/24/2020 :�Qx Commonwealth of Massachusetts RECEIVED
City/Town of
- System Pumping Record AUG 2 4 2020
TOWN OF NORTH ANppVER
Form 4 HEALTH DEPARTMENT
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 Locatio Le -gh n of house,,)Left/Right rear of house, Left/right side of house, Left
Right side of building, Left/Right front of building, Left/Right rear of building, Under deck
Address � � ` �- � r--
Cityrrown State Zip Code
2. System Owner.
Name
Address(if different from location)
CitylTown g� ,..-- C Zip� e
Telephone Number r
B. Pumping (record
1. Date of Pumping gate 2 Q 'ty Pumped: Gallons
3. Type-of system: ❑ Cesspool(s) ; eptiu
c Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes No 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.isigne
RIHtawl
ontents were disposed:
Lowell Waste Water
MuData
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