HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 120 HAY MEADOW ROAD 9/20/2019 Commonwealth of Massachusetts
City/Town of
System Pumping Record SEP 20 2019
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 hous Le fight ear of hou e, Left/right side of house, Left
Right side of building, Left/Right front of building, Left/Right rear of building, Under deck
Address ! 1 -
Ctwrown State Zip Code
2. System Owner.
Name
Address(if different from location)
Cityfrown State Zip Code
4C_1 0"?-5 l
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2- Quantity Pumped: Gallons
3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes o If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of Sy t m:
VLA�t� [ �C a ,
6. System Pumped By:
Neil.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Loca' contents{were disposed:
G L S.j ILowell Waste Water
Sign a Haul Date
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