HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 167 GRANVILLE LANE 12/7/2020 .�L\ Commonwealth of Massachusetts RECEIVED
City/Town of DEC 0 7 2020
System Pumping Record TOWN OF NORTHANDO
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 AR 64 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 l&`7 �k—.4�Z
Citylrown State Zip Code
2: System Owner.
Name
Address(if different from location)
Citylrawn State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping pate 2. Quantity 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. Locationylaer@ contents were disposed:
G L S. ) Lowell Waste Water
Signitule Haul Data
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