HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 10/16/2019 Commonwealth of Massachusetts
City/Town of
System Pumping Record
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 hous , 'g rear of hou . , Left/right side of house, Left
Right side of building, Left/Right front of bul irig, Left/ g rear of building, Under deck
Address lc_� r`1 5 ,^�
City/Town `� State Zip Code
2. System Owner. LaA�
Name
Address(if different from location)
CityylTown State
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 If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of Sys :
6. System Pumped By:
Neil.Batesbn F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Loca' ere contents{were disposed:
G L S Lowell Waste Water
Sign We ItHaulwt Date
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