HomeMy WebLinkAboutseptic tank - Septic Pumping Slip - 90 WINDSOR LANE 10/1/2019 , v_1
: Commonwealth of Massachusetts
City[Town of
System Pumping Record
Form 4
1 W_
DEP has provided this form for uwby 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 house, Left I Right rear of house, Left 1 st a of house, Left
Right side of building, Left/Right front of building, Left/Right rear of building,g n m-&c- c_._
Address I1 i /
City/rown N State Zip Code
2. System Owner.
Name*
Address(if different from location)
CWrown State
Telephone Number
B. Pumping record
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Type-of system: ❑ cesspool(s) piic 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.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Ina
Company
7. Loca' �e contents were disposed:
L S Lowell Waste Water
Sign We qt HaulwU Date
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