HomeMy WebLinkAboutseptic tank - Septic Pumping Slip - 40 STERLING LANE 10/1/2019 Commonwealth of Massachusetts
City/Town of
M° System Pumping Record OCT 0 2010
Form 4 Tow, Cr uwrt
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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/Igof ft!Right rear of house, Left/right side of house, LeftRight side of building, Lron-o building, Left/bight rear of building, Under deck
Address
Cityrrown (! state Zip Code
2. System Owner.
Name'
Address(if different from location)
citylTown sta Zi Code
ae
Telephone Number
B. Pumping Record
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? ❑ 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 Inc-
Company
7. Location where contents-were disposed:
G L S Lowell Waste Water
M a- A
SignAture 9t Haulwu Date
t5form4.doc-06103 System Pumping Record•Page 1 of 1