HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 125 SAW MILL 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.fhis 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/Vight r -ar 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
CWTown State Zip Code
2. System Owner.
Name
Address(of different from location)
City/Town Stag. Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2- Quantity Pumped: Gallons
3. Type of system: ❑ Cesspool(s) aZe---p--tic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes ryc If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
6. System Pumped By:
Neil.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc-
Company
7. Location-where contents were disposed:
G L gHaul
Lowell Waste Water
- f f
Sign Date
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