HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 128 MILL ROAD 4/28/2021 Commonwealth of Massachusetts L`',27®
City/Town of
System Pumping Record APR 2 8 2021
TOWN OF NORTH A UOVCR
Form 4 HEALTH
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 douse, Left/Right rear of houseA�rng��
se, eft
Right side of building, Left/Right front of building, Left/Right rear of 6ui�
Address � �� � � U
city/Town state Zip Code
2. System Owner.
Name'
Address(W different from location)
stagy� Zip Code
Telephone Number
B. Pumping Record /
1. Date of Pumping Date 2. Qu, City Pumped: Gallons
3. Type of system: ❑ Cesspool(s) eptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes o If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System: ��_✓��� ��J� � 1/l._,
L_
6. System Pumped By:
Neil.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Lo contents-were disposed:
MeH�auwlwu,
Lowell Waste Water
SignDate
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