HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 75 GRANVILLE LANE 9/22/2021 :4txCommonwealth of Massachusetts RECEIVED
City/Town of
System Pumping Record SEP 2 2 zo2
Form 4 TOWN OF NORTH ANDWER
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 Location: Left/Right front of house, Left/Right rear of house, e�it/ '9 s�qls eft/
Right side of building, Left/Right front of building, Left/Right rear of b�iid"mg, Und
Address
cityfrown State Zip Code
2. System Owner.
Name
Address(if different from location)
cWrown
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2. Qu' tity Pumped:
Gallons
3. Type-of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes 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. Locatio contents-were disposed:
lee
S Lowell Waste Water
Haul Date
tftrm4.doc-06/03 System Pumping Record•Page 1 of 1