HomeMy WebLinkAboutSewer Ejector Tank - Septic Pumping Slip - 455 CHESTNUT STREET 1/25/2021 : Commonwealth of Massachusetts
City/Town of RECEIi/ED
System Pumping Record JAN ? 5 70?'
Form 4
}-OWN Or NORTH ANDUVER
DEf 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 ft/ ght house, e#t/right side of house, Left/
Right side of building, Left/Right front of bul g, Left/Right rear of building, Under deck
Address
Cjty/1 am state Zip Code
2. System Owner.
Name' VJ
Address(if different from location)
City/Town state-
Telephone Number
B. Plumping Record
1. Date of Pumping Date 2. Quantity Pumped: Gauons
3. Type-of system: ❑ Cesspool(s) El Septic Tank ❑ Tight Tank
a,OIfier(describe):
4. Effluent Tee Filter present? ❑ Yes ❑ No If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System: ,Ozt�
6. System Pumped By:
Neil.Bateson _ F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Location where contents,were disposed:
�L Lowell Waste Water
signAkWA qrHaul Date
t5form4.doc-06/03 System Pumping Record•Page 1 of 1
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