HomeMy WebLinkAboutseptic tank - Septic Pumping Slip - 32 DEER MEADOW ROAD 10/1/2019 Commonwealth of Massachusetts
_ City/Town of
System Pumping Record OCT 01 201A
TOWN Cr
Form 4 r
DEP has provided this form for usez 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 house, Left i ht rear of house; Left/right side of house, Left 1
Right side of building, Left/Right front of building, Left/ g rear of building, Under deck
Address
City/Town State Zip Code
2: System Owner.
Name'
Address(if different from location)
City/Town State �0 Zip Code, C ��
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped:
Gallons
3. Type of system: ❑ Cesspool(s) ET-Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes D-No If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of Syste :
6. System Pumped By.
Neil Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. LocatioffWhere contents-were disposed:
G L SJOI Lowell Waste Water
SignAtute 9t Haul Date
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