HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 129 CHRISTIAN WAY 1/14/2021 : Commonwealth of Massachusetts ' s
_ City/Town of JAN 14 2021
System Pumping Record TOWN OF NORTH""OVER
Form 4 HEALTH DEPARTNIE
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 e R(gh of hous(! 'Left/Right rear of house, Left I right side of house, Left
Right side of bui(�Peft/Right front o uitding, Left/Right rear of building, Under deck
Address k �� /ice V�; �� C « W -`� W�--4�
Citylrown State Zip Code
2. System Owner.
Name
Address(i different from location)
Citylrown State Code ,
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Type of system: ❑ Cesspool(s) tic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? es ❑ No If yes, was it cleaned? ' es ❑ No
5. Condition ofASystem-
6. System Pumped By:
Neil.Bates-on F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Location where sQntents,were disposed:
G L S Lowell Waste Water
SignAtufe cf HaulmuDate
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