HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 230 FOREST STREET 4/28/2021 Commonwealth of Massachusetts RECEIVED. City/Town of
System Pumping Record APR 2 8 2071
Form 4 TOWN OF NORTH ANU- _
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 k Cjht front of house; 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
City/Town State Zip Code
2: System Owner.
Name
Address(if different from location)
CiWown State_., Zip Code
Telephone Number
B. Pumping record
1. Date of Pumping Date 2. Quantity Pumped:
Gallons
3. Type of system: ❑ Cesspool(s) alieptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes L_t'Mo 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. Location_vAmKe contents-were disposed:
4gn
pHaulo
Lowell Waste Water
L-( rq 0 Date
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