HomeMy WebLinkAboutSewer Lift Station - Septic Pumping Slip - 476 GREAT POND ROAD 12/16/2020 Commonwealth of Massachusetts RECEIVED
City/Town of
System Pumping Record DEC 16 2020
Form 4 TOWN OF NORTH ANDUVIM
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 bystem Pumping Record must be submitted to
the local Board of Health or other approving autho*.
A. Facility Information
1. System Location: Left/Right front of house, Left/Right rear of h use, Left/right side of house, Left
Right side of building, Left/Right front of building Righ ar buildin , Under deck
Address �—
1 �
City/Town State Zip Code
2. System Owner.
Name
Address(if different from location)
CWrown State /o -(4 C p,
Telephone Number �l
B. Pumping record
1 2 '-Li e�
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Type-of system: ❑ Cesspool(s) ❑ Septic Tank ❑ Ti ht Tank
❑P10t'her(describe):
4. Effluent Tee Filter present? ❑ Yes ❑ No If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
6. System Pumped By:
Nell.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Ina
Company
7. Locatio ere contents-were disposed:
�L S Lowell Waste Water
L -_� - L4-Jo,--
Signitie qt HaulwU Date
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