HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 450 BOSTON STREET 4/28/2021 Commonwealth of Massachusetts RECEIVED
= City/Town of
System Pumping Record APR 2 8 2021
Form 4 TOWN OF NORTH AMC
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 Left ' h side cf h e Deft
Right side of building, Left/Right front of building, Left/Right rear of building, Un
Address
City/Town State Zip Code
2. System Owner.
Name
Address(if different from location)
city/Town State Zip 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? EjY€V❑ No If yes, was it cleaned? �es ❑ No
5. Condition of System:
6. System Pumped By:
Neil.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc-
Company
7. LocaWlW " contents-were disposed:
Lowell Waste Water
SignAtufe it HaulwU Date
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