HomeMy WebLinkAboutseptic tank - Septic Pumping Slip - 700 MIDDLETON STREET 1/14/2021 Commonwealth of Massachusetts j J
City/Town of JAN 14 2021
System Pumping Record T UPIN OF NORTH ANDOTM
Form 4 A,,,Tl-1 DEPARTMENT
DEf has provided this form for use-by local Boards of Health. Other forms maybe 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 rear of hous# Left/right side of house, Left 1
Right side of building, Left/Right front of building, Left/Right rear of building, Under deck
Address
My'rrown State Zip Code
2. System Owner.
Name
Address(if different from location)
43 crl :
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped:
Gallons
3. Type-of system: ❑ Cesspool(s) eptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? es 0 No If yes, was it cleaned? ErYes [] No
5. Condition of System:
6. System Pumped By:
Neil.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. LonSJQ
re contents-were disposed:
77L. Lowell Waste Water
Sign aqtHglulwuDate
t5fomm4.doc•06/03 System Pumping Record•Page 1 of 1