HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 300 FOSTER STREET 8/4/2021 Commonwealth of Massachusetts RECENED
City/Town of AUG 0 4 2021
System Pumping Record TOM OF NORTHANDO,4ER
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 Locatio Le fight front of house, Left/Right rear of house, Left I right side of house, Left
Right side of building, Left/ Right front of building, Left/Right rear of building, Under deck
Address (/
L 144'e'e— (5 A
frown State Zip Code
2. Sys Owner
Name
Address(if different from location)
Citylrown State �0 y/ Z' Code
Telephone Number
B. Pumping Record
l
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 ❑ No if yes, was it cleaned? Yes ❑ No
5. Condition of System: ` W101
6. System Pumped By:
Neil.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Location where contents-were disposed:
Lowell Waste Water
Sign LeWHtaiulwU)) Date
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