HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 60 TIFFANY LANE 10/1/2019 g�Gs`gvD
: Commonwealth of Massachusetts pC� p ; 201°'
City/Town of �Arj0\A
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/ ' t front of house, ft/Right rear of house, Left/right side of house, Left/
Right side of building, Left/ I i ding, Left/Right rear of building, Under deck
Address '�
Cityrrown �j state Zip Code
2. System Owner.
C'
Name"
Address(if different from locafion)
CitylTown Stateenda
r�-' , ,,. -
Telephone Number
B. Pumping Record
q .� l
1. Date of Pumping oar_ �;2. Qua 'ty 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 System;
6. System Pumped By:
Neil.Batesbn F5821
Name Vehicle License Number
Bateson Enterprises Ina
Company
7. LoMLL
b are contents-were disposed:
Lowell Waste Water
signk4e cfHaulwU Date
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