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HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 60 SUNSET ROCK ROAD 9/7/2021 .�C\_ Commonwealth of Massachusetts RECEIVED City/Town of System Pumping Record SEP 0 7 2021 Fonn 4 TOWN OF NORTH AN©OVER DEP has provided this form for use-by local Boards of Health. Other forms may be used,but the information,must be substantia1ly 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 eft Right nt of hou Left/Right rear of house, Left/right side of house, Left 1 Right side of bud i , Left/Rig front of building, Left/Right rear of building, Under deck Address60 City/Town ate 1/ Zip Code 2. System Owner. Name. Address(if different from location) CitylTawn State p Code d% Tel one Number C B. Pumping Record �� 1. Date of Pumping 2 Quantity Pumped: Date Gallons 3. Type-of system: ❑ Cesspool(s) eptic Tank ❑ Tight Tank ❑ Other(describe): 4. Effluent Tee Filter present? ❑ Yes D,IQo 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. Locati where contents-were disposed: L S Lowell Waste Water -0Ae Signk4e qt HbuleifData t51brm4.doc•06/03 System Pumping Record•Page 1 of 1