HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 41 NORTH CROSS ROAD 10/5/2021 Commonwealth of Massachusetts RECEIVED
City/Town of OCT o
System Pumping Record ro 5 ?���
WN OF NoRT
Form 4 HEALTH r,,I,,H,AND
JTER
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 Informlation
1. System Location: Left/Right front of h sQ,�ft/'Right�re-ar of house Left/right side of house, Left/
Right side of building, Left/Right front of b l5rig, Left/Rfg-ff rear of building, Under deck
Address � r
City/Town State Zip Code
2: System Owner.
D�YNKA&nName �—
Address(if different from location)
City/Town S Zip Code
Telephone Number
.B. Pumping Record
1. Date of Pumping Date Quantity Pumped: GaIlDns
3. Type of system: ElCesspool(s) [} Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes ❑--too If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of Syst
6. System 1 Pumped
pe
e� F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Locafi re contents were disposed:
L S Lowell Waste Water
Sign aCt Hlgule� t Date
5form4.doca 06/03 System Pumping Record•Page 1 of 1