HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 58 OAKES DRIVE 9/20/2019 Commonwealth of Massachusetts SEP 20 2019
City/Town of
System P-umping Record
Form 4
DEP has provided this form for usez by local Boards of Health. Other forms may beused, 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, Lefty t re___re____Quse, Left/right side of house, Left
Right side of building, Left/Right front of building, Left/Right rear of building, Under deck
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City/Town state Zip Code
2: System Owner.
Name
Address(if different from location)
Cityffown Stat /Z'p Code
Telephone Number
B. Pumping Record
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1. Date of Pumping Date 2• Quantity Pumped: Gallons
3. Type of system: ❑ Cesspool(s) eptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? "es `to if yes, was it cleaned? D-Y6s---❑ No
5. Conditi n f�stem*�
6. System Pumped By:
Neil.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc-
Company
7. Locati'm-where contents were disposed:
G L a. Lowell Waste Water
Sign a 9f Hauleq Date
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