HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 75 LOST POND LANE 4/28/2021 Commonwealth of Massachusetts RECEIVED
City/Town of APR 2 8 2021
System Pumping Record TOWN NOR!I�ANi�(�Vl t�
Y p g HEALTH ni<PARTMENT
Form 4
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(j�4t/Righfl nt.-ra£kiouse`Left/Right rear of house, Left/right side of house, Left 1
Right side of building, Left/Right front of building, Left/Right rear of building, Under deck
Address _ rr � `` �/
City/Town state Zip Code
2: System Owner. (C'
Name
Address(if different from location)
City/Town State Zip Code
'To - f,l"2 ^ ►Q�`�'
Telephone Number
B. Pumping Record
1. Date of Pumping Date I Quantity Pumped:ed: Gallons t
3. Type of system: ❑ Cesspool(s) [Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
r
6. System Pumped By:
Neil.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc-
Company
7. Location-where contents-were disposed:
G L AS. ', Lowell Waste Water
Sign Date
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