HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 44 CRICKET LANE 9/20/2019 Commonwealth of Massachusetts RECEIVED
City/Town of
System Pumping Record SEP 2 0 2019
Form 4
TOWN OF�rPTH A�IYWER
DEP has provided this form for use=by local Boards of Health. Other forms maybe*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 rght'rear of house eft/right side of house, Left
Right side of building, Left/Right front of building, e g rear of building, Under deck
Address
CityRown State Zip Code
2. System Owner.
Name'
Address(if different from location)
GWTwm State Tip Code
7
Telephone Number
B. Pumping record
1. Date of Pumping Date _ r �Z2. uantity Pumped: Gallons
3. Type-of system: ❑ Cesspool(s) c Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? Yes No If yes, was it cleaned? Yes ❑ No
5. Condition of stem:
+4 �
Qo a r �d CLS, i C C a LAO(j"Q
6. System Pumped By:
Neil.Batesbn F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Location where contents were disposed:
L S Lowell Waste Water
Sign e Haul Date �-�---=—�
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