HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 140 CHRISTIAN WAY 11/19/2020 Commonwealth of Massachusetts RECEIVED
City/Town of NOV 19 Z0?0
System Pumping Record To ft'FNORTH
HNTH DEPARTMENT
ER
Form 4 s.. 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, Left/Rtaht ear 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
Cityfrown Zip Code
2. System Owner.
Name
Address(if different from location)
CitylTawn State,-, t y np C.ocie n
Telephone Number �j `-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 LJ ,o 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:
C31 S. Lowell Waste Water
Sign a Haul Date
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