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HomeMy WebLinkAboutD-Box / Septic Tank - Septic Pumping Slip - 1620 TURNPIKE STREET 10/16/2019 Commonwealth of Massachusetts ,r _ City/Town of OCT 16 Z019 System Pumping Record Form 4 T 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 o use Left/Right rear of house, Left/right side of house, Left Right side of building, Left ig- fro__nt of buildin Left/Right rear of building, Under deck Address CWrown State Zip Code 2, System Owner. Name' Address(if different from location) Cityrrown State' ZipCode Telephone Number B. Pumping Record 1. Date of Pumping Date 2. Quantity Pumped: Gallons 3. Type of system: ❑ cesspool(s) 3-teptic Tank ❑ Tight Tank (3—CA-h-e­r(describe): 4. Effluent Tee Filter present? ❑ Yes ❑ No If yes, was it cleaned? ❑ Yes ❑ No 5. Condition of Sy m: �4_ „ v J Qv\-C, �Q tA-0.�� 6. System Pumped By: Neil Batesbn F5821 Name Vehicle License Number Bateson Enterprises Inc Company 7. Locatio re contents.were disposed: G L S Lowell Waste Water Signibife 9t HaulwU Date t5form4.doc•06/03 System Pumping Record•Page 1 of 1