HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 434 BOXFORD STREET 8/4/2021 :�L\ Commonwealth of Massachusetts RECEDED
City/Town of
System Pumping Record Allis o 4 ?07`
Form 4 TOWN OF NORTH ANUUVER
HEALTH DEPARTMENT
DEP has provided this form for us&by local Boards of Health. Other forms may *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 Infor ation
1. System Locati : Left Right front of house, Left/Right rear of house, Left/right side of house, Left/
Right side Qfbu eft/Right fron of buildin , Left/Right rear of building, Under deck
Address
a /� 4 1< �
CRY/Tow State Zip Code
2. Sy Owner.
70
Name
Address(if different from location)
CityrTow stater
Telephone Number
B. Pumping record
1. Date of Pumping Cate 2. Quantity Pumped:
Gallons
3. Type of system: ❑ Cesspool(s) 4Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes` No If yes, was it cleaned? ❑ Yes ElNo
5. Condition of System:
6, System Pumped By:
Neil.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Locati ere contents were disposed:
�?G_ S Lowell Waste Water
%-j(tMOA.
sign We ObulffluDate
t5fomu4.doc-06/03 System Pumping Record•Page 1 of 1