HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 103 VEST WAY 9/9/2019 Commonwealth of Massachusetts
ONIMEMEMOM
City/Town of
System Pumping Record
Form 4
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: Left4tf Igh front of hou Left/Right rear of house, Left/right side of house, Left
Right side of building, Lef_tTFZij-hTTr-6-nT-of building, Left/Right rear of building, Under deck
Address
Citynown fate Zip Code
2. System Owner. � D
Name" L
Address(if different from location)
CiLyJTown
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Type of system: ❑ Cesspool(s) ptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes o If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System: ��r M Ct�t (IA4 /
6. System Pumped By:
Neil.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Loca. contents-were disposed:
G L S Lowell Waste Water
A.
sign We cfHauieUDate
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