HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 137 BRIDGES LANE 11/12/2020 Commonwealth of Massachusetts RECEIVED
City/Town of
m Pumping Nov 12 2020
System ping Record
TOWN OF NORTH ANDOI
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 hou , Left/right side of house, Left
Right side of building, Left/Right front of building, a rear of building, Under deck
Address
City/Town state Zip Corye
2. System Owner. ' I
Name
Address(if different from location)
City/Town
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2. 9aantity Pumped: Gallons
3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes 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-Q Lowell Waste Water c�SignAtule I Haul Date
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