HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 30 SUMMER STREET 9/7/2021 : Commonwealth of Massachusetts
City/Town of RECEIVED
System Pumping Record SFP o 7 2021
Form 4 TOWN OF NORTH ANDl7Vr_R
HEALTH DEPAI-
DEP has provided this form for use=by local Boards of Health. Other forms may�e 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�Le` Righ of hou Left/Right rear of house, Left/right side of house, Left
Right side of building, Left/Right front of building, Left/Right rear of building, Under deck
Address
:�Z� S'
Cityrrown State Zip Code
2. System Owner.
Name'
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping record
—Del
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Type of system: ❑ Cesspool(s) tic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes No If yes, was it 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:
_L S Lowell Waste Water
fl
Signitule ctHaulwUDate
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