HomeMy WebLinkAboutseptic tank - Septic Pumping Slip - 40 STERLING LANE 10/1/2019 (3) Commonwealth of Massachusetts
City/Town of OCT 0 12019
System Pumping Record
Form 4 TOWN OF NCM'H AND
OVrn
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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 Mt�h#fro of house}„Left/Right rear of house, Left/right side of house, Left/
Right side of building, Left/Right front of building, Left/Right rear of building, Under deck
Address
Cityfrown �state` Zip Code
2: System Owner.
Name'
Address(if different from location)
CitylTown State ^ � ��de
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2_ Qu ty Pumped: Gallons
3. Type of system: ❑ Cesspool(s) eptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes f O If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of,Systern:
6. System Pumped By:
Neil.Batesbn F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Location where contents-were disposed:
Lowell Waste Water
4&igniWfe Haul Date
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