HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 1659 OSGOOD STREET 9/20/2019 : Commonwealth of Massachusetts
_ City/Town of SEP 20 2019
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: Left/Right front of house, Left/Right rear of house, Left/right side of house, Left
Right side of building, Left/Right front of building, Left/Right rear of building, Under deck
Address ^�
City/Town ( < State Zip Code
2. System Owner.
Name'
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped: dailons
3. Type of system: ❑ Cesspool(s) 0-SepticTank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes 0_M0____ If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
6. System Pumped By:
Neil.Bates-on F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Location wbere contents,were disposed:
.L S Lowell Waste Water
t
sjgniture q H'aulev Date
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