HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 122 FOSTER STREET 6/24/2021 : Commonwealth of Massachusetts
JIMMMEMM
City/Town of RECEIVED
System Pumping Record JUN 2 4 2.071
Form 4
Tn�Pjr!OF NORTH ANOUVER
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, Left/Right rear of house, Left/ ' ide 9f house, Left
Right side of building, Left/Right front of building, Left/Right rear of building, Under deck
Address
Myrrown state Zip Code
2. System Owner.
Name'
Address(if different 1+,joption� )
CiWTown C0-�7,
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Type-of system: ❑ Cesspool(s) eptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes ailo If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
6. System Pumped By:
Neil.Batesbn F5821
Name Vehicle License Number
Bateson Enterprises Ina
Company
7jSV7199n
contents,were disposed:
Lowell Waste Water
F ulwu Date
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