HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 185 GREAT POND ROAD 7/8/2021 :4QxCommonwealth of Massachusetts RECERPED
City/Town of
System Pumping Record Ali- 0 U912'
Form 4 T®WN®F NORTH ANOOVER
��ALTH DEPARTMENT
DEP has provided this form for use-by local Boards of Health. Other forms may be but the
information must be substantially the tame 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, Left Left./right side of house, Left
Right side of building, Left/Right front of building, Left/Right rear of building, Under deck
Address
Citylrown state Zip Code
2. System Owner.
Name.
Address(if different from location)
Cityrrown State L4 Zip Code
1 -7
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped:
Gallons
3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System•
6. System Pumped By:
Neil.Bateson F5821
Name Vehicle Ucense Number
Bateson Enterprises Inc
Company
7. Location where contents were disposed:
_L S Lowell Waste Water
Sign a Haul Date
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