HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 79 ROCKY BROOK ROAD 1/25/2021 Commonwealth of Massachusetts RECEIVED
City/Town of
System Pumping Record JAN
Form 4 TOWN OF NORTHANDO/cR
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 house
d ek-l-right Jd7e o'fhous , Left/
Right side of building, Left/Right front of building, Left/Right rear of building, Under deck
Address
CWrown =� G�J S/tateV Zip code
2. System Owner.
Name
Address(f different from location)
Cityrrown State Zi Code
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped:
Gallons
3. Type of system: ❑ Cesspool(s) [ "Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes 0'No If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
6. System Pumped By:
Neil.Batesbn F5821
Name Vehicle License Number
Bateson Enterprises Inc-
Company
7. Locati here contents were disposed:
Lowell Waste Water
Sign a I HaulwU Date
t5form4.doc 06103 System Pumping Record•Page 1 of 1
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