HomeMy WebLinkAboutseptic tank - Septic Pumping Slip - 192 STONECLEAVE ROAD 10/1/2019 Commonwealth of Massachusetts � �
City/Town of �w p; Jo\g
System Pumping Record
Form 4 ,�o `J��pEPPF
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 ,'Laft/Rigt#CT ar of house;Left/right side of house, Left
Right side of building, Left/Right front of but ding, Left/Right rear of building, Under deck
Address
cityrrowh State Zip Code
2. System Owner.
Name
Address(if different from location)
CityfTown State i/ Zip Code
Telephone Numb
B. Pumping Record
1. Date of Pumping S I O
Date Quanti Pumped:
Gallons
3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank
❑ Other(describe):
i
i
4. Effluent Tee Filter present? ❑ Yes [] No 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:
Lowell Waste Water
Signitufe f PHaulg����� Date
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