HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 20 NORTH CROSS ROAD 4/28/2021 : Commonwealth of Massachusetts RECEIVED
_ City/Town of APR 2 8 ZOV
System Pumping Record OF NORTHANOD��R
Form 4 TD HEALTH DEPARTMENT
DEP has provided this form for use=by local Boards of Health. Other forms may beused, 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, etch I e of�l ouse, eft 1
Right side of building, Left/Right front of building, Left/Right rear of but mg, Un er;de�
Address
City/Town State Zip Code
2. System Owner.
�Gc rc S
Name
Address(if different from location)
Cityfrown Sta Zip Code
Telephone Number
B. Pumping Record 1. Date of Pumping Date 2. Quantity Pumped:
i Gallons
3. Type of system: ❑ Cesspool(s) [-Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes LSO If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System: cA_
J�z
6. System Pumped By:
Neil.Batesbn F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Location where contents were disposed:
11 �
ISign
S. Lowell Waste Water
a Haul Date
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