HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 35 TIFFANY LANE 9/7/2021 :� Commonwealth of Massachusetts RECEIVED
City/Town of SEP 0 7 2021
System Pumping Record TOWN OF NORTH DEPARTMENR T
Form 4
DEP has provided this foram for use-by local Boards of Health. Other forms maybe*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/ ht front of house Left/Right rear of house, Left/right side of house, Left
Right side of building, Left/Rig ron o uildirig, Left/Right rear of building, Under deck
Address -� I� rc/VhLi LV`�V�=r�
City/Town state Zip Code
2. System Owner.
Name'
Address(if different from locatlon)
Cityfrown " P Code
c�-�
Telephone Number
B. Plumping Record
1. Date of Pumping Date 2 Quantity Pumped:
Gallons
3. Type-of system: ❑ Cesspool(s) a-Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes If yes, was A cleaned? ❑ Yes ❑ No
5. Condition of System:
6. System Pumped By:
Neil.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Location where contents-were disposed:
ACI S Lowell Waste Water
4AAA
'5ignAWe qt HhulerU Date
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