HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 145 COLONIAL AVENUE 11/23/2020 Commonwealth of Massachusetts RECEIVED
City/Town of NOV 2 3 2020
System Pumping Record TOWNpFNORTHANooVER
Form 4 HEALTH 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, 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
CiWTown state Zip code
2. System Owner.
Name
Address(if different from location)
CiVrown State �p Code
Telephone Number
B. Pumping Record
CC) -a? 1 '
1. Date of Pumping (LDDate 2• Quantity Pumped: Gallons
3. Type of system: ❑ Cesspool(s) eptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes LSO 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. LopationVii-M contents were disposed:
G_L S.P Lowell Waste Water
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Sign a Naul pate
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