HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 7 INGALLS STREET 10/21/2019 : Commonwealth of Massachusetts RECEIVED
City/Town of SEP 2 3 2019
V System Pumping Record
Y P 9 Form 4 BOARD OF HEALTH
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/Right rear of hous. , _e / ' side of house.+Left t
Right side of building, Left/Right front of building, Left/Right rear of bui dl ing, under ec
Address y--� -�' � S
1 ` z f\! U
Cityrrown State Zip Code
2. System Owner.
Name
Address(if different from location)
Cityff own State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2- Quantity Pumped: Gallons
3. Type of system: ❑ Cesspool(s) 9-5eptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes O If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
6. System Pumped By:
Neil.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Locati nwhera contents were disposed:
G L S: Lowell Waste Water
V
Sign a Haul Date
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