HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 1493 FOREST STREET EXT 8/24/2020 Commonwealth of Massachusetts RECEIVED
City/Town of AUG 2 4 2020
System Pumping Record TOWNOFNORTHA' -
Form 4 FZ40H DEEPAn ;
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 �, eft
ig ront of house, Left/Right rear of house, Left/right side of house, Left
Right side of bull /Rigfffront of building, Left/Right rear of building, Under deck
/ J O Address
roJ CiWrown State Zip Code
2. System Owner. D , _ rA
lk-
Name
Address(if different from location)
City/Town St Zi e
Telephone Number
B. Pumping Record
1. Date of Pumping Date 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:
6. System Pumped By:
Neil.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc-
Company
7. Location where contents-were disposed:
G L S_P Lowell Waste Water
Sign a Haul Date
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