HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 459 SALEM STREET 6/24/2021 Commonwealth of Massachusetts E EcIVEO
City/Town of R
System Pumping Record 30N 2 4 20
Form 4 N OF NORTH WDvvER
1 0`N NTH DEPF.QT��cNT
DEP has provided this form for use=by local Boards of Health. Other form.6ay 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 effg rout house, Left/Right rear of house, Left/right side of house, Left
Right side of bui g, Left/Rlg ron o uilding, Left/Right rear of building, Under deck
Address J , q -.
City/Town State Zip Code
2. System Owner.
Name
Address(if different from location)
City/Town Stat Zip code
a - 5 �
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2- Quantity Pumped:
Gallons
3. Type of system: ❑ Cesspool(s) [3'Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? Yes 0 No If yes, was it cleaned? es ❑ No
5. Condition of System:
6. System Pumped By:
Neil Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Loca.0 contents=were disposed:
G L S Lowell Waste Water
4S&gnjWje Haul Date
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