HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 150 BRADFORD STREET 11/23/2020 Commonwealth of Massachusetts RECEIVED
City/Town of NOV 2 3 2020
System P-um ping Record TOWN OF NORTH AN00"r—
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 LocatiorK jzff/'Right ont 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
City/Town —� State Zip Code
2: System Owner.
�-t 1
Name
Address(if different from location)
Cityffown State" Zip Code
`r3iS
Telephone Number
B. Pumping Record
1. Date of Pumping i c` �� 2 U 2. Quantity Pumped: 1
Date Gallons c�
3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes �o If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
c
6. System Pumped By:
Neil.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc"
Company
7. Location where contents were disposed:
Lowell Waste Water
Signitute qt Haul Date
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