HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 50 LOST POND LANE 10/16/2019 Commonwealth of Massachusetts
City/Town of
System Pumping Record 16 ?019
Form 4
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 house, Left J Right rear of house, Left ola-fif side of hou eft 1
Right side of building, Left/Right front of building, Left/Right rear of building, Under deck
Address
City/Town state Zip Code
2. System Owner:
Name
Address(if different from location)
Cityfrown state Zi Code
Telephone Number
B. Pumping Record
1. Date of Pumping Date Pumped: Gallons �� ~
3. Type of system: ❑ Cesspooi(s) Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes No if yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
(�(c/L/t_
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
gjE��ii;�—
Sign a Haut Date
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