HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 80 SUTTON HILL ROAD 4/28/2021 :�L\ Commonwealth of Massachusetts RECEIVED
City/Town of
System Pumping Record APB 2 $ �az1
TOWN OF NORTH AN9OVCfR
Form 4 HEALTH DEPARTMIENT
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,&inq, Leeft/Rig
g rear of�hou 'Left/right side of house, Left
Right side of building, Left/Right front of bu rear of building, Under deck
Address Q �(
City/Town State Zip Code
2. System Owner.
Name
Address(if different from location)
CitylTawn State��— VTrp Code
Telephone Number +^(7
.B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped:
Gallons
3. Type-of system: ❑ Cesspool(s) ptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes Ulwo if yes, was it cleaned? ❑ Yes ❑ No
5. Condition of Systoln: n , ,
6. System Pumped By:
Neil.Meson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Locatio here contents-were disposed:
L S Lowell Waste Water
Signitufe qt Haul Date
tftffn4.doc•06/03 system Pumping Record•Page 1 of 1