HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 322 BOSTON STREET 9/25/2020 Commonwealth of Massachusetts RECENED
City/Town of SEP 2 5 201
System Pumping Record TO"OF NORTH ANppVER
Form 4 HF 0L H 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 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 house eft/,Rig ear of house,left/right side of house, Left
Right side of building, Left/Right front of b g, Left rear of build-mg, Under deck
Address �On6x_'
Cityrrown State Zip Code
2. System Owner.
Name =v'
Address(if different from location)
Cityfrown State r Zi Code
?—(?L l�-
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? es ❑ No If yes, was it cleaned? ❑-Yes-[f No
5. Condition of� tem_:
� J f`tip
6. System Pumped By:
Neil.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. L"tione contents-were disposed:
Lowell Waste Water
Signiture Haul Date
t5form4.doa 06/03 System Pumping Record•Page 1 of 1