HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 499 WINTER STREET 4/28/2021 Commonwealth of Massachusetts RECEIVED
_ City/Town of APR 2 8 2021
System Pumping Record
TOWN OF N()R1H ANUUVER
Form 4 HEALTH DEPARTMENT
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 forrh 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 Alight-rear of hour, Left/right side of house, Left 1
Right side of building, Left/Right front of building, Left/Right rear of building, Under deck
Address St ,' a -/�K
City/Town (�JC State 1p� Zip Code
2. System Owner. S�
Name
Address(if different from location)
City/rown State O Zi Code
-
Telephone Number
B. Pumping Record I
1. Date of Pumping vat` _� 3c) ( 2. Quantity Pumped: �2C�
Gallons
3. Type of system: ❑ Cesspool(s) eptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes [ No If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
6. System Pumped By:
Neil.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc-
Company
7. Loca' contents-were disposed:
G LSQ Lowell Waste Water
Signitufe 9t HaulwU Date
t5form4.doc-06/03 System Pumping Record•Page 1 of 1