HomeMy WebLinkAboutPump Tank - Septic Pumping Slip - 465 CHESTNUT STREET 7/8/2021 Commonwealth of Massachusetts RECEIVED
City/Town of ;Ul p g Zp2.1
System Pumping Record TO,,�fNOF NORTH ANOOVER
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 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,(eft_TAigh ear of hous. Left/right side of house, Left
Right side of building, Left/Right front of building, Left/Rig rear of building, Under deck
Address
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CfWrown State Zip Code
2. System Owner.
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Name
Address(if different from location)
CitylTawn State- ,._, � � Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping p g Date Quantity Pumped: Gallons
3. Type of system: ❑ Cesspool(s) ❑ Septic Tank ❑ Tight Tank
QL--L�
ther(describe): C�.�l� -
4. Effluent Tee Filter present? ❑ Yes ❑ No If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of Sy
6. System Pumped By:
Neil.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc-
Company
7. Location where contents were disposed:
L S. Lowell Waste Water
Signitute 9t Haul Date
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