HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 154 ROCKY BROOK ROAD 10/5/2021 .14- Commonwealth of Massachusetts �ECEIV
City/Town of T p J ,
System Pumping Record TOWN OF NORTH AND
Form 4 HEALTH jo
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 forrh 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, Righ rear o ho 0, Left/right side of house, Left
Right side of building, Left/Right front of building, Left/ of building, Under deck
Address
City/Town state Zip Code
2. System Owner.
Name
Address(if different from bcatton)
CitylTown state��- _jQ��
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped:
Gallons
3. Type of system: ❑ Cesspool(s) 9-leptic 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. Locati where contents-were disposed:
�L Lowell Waste Water
-W,&A
S7g_nJiTe cf HaLdwU Date
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