HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 81 BRADFORD STREET 10/21/2019 Commonwealth of Massachusetts
91 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 0 gh front of hou Left/Right rear of house, Left/right side of house, Left/
Right side of building, Le fight fron o building, Left/Right rear of building, Under deck
Address P,
City/Town `( State Zip Code
2. System Owner.
Name
Address(if different from location)
CWTown $in c code
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 a J Wo 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. Locaticia3uhare content were disposed:
L S Lowell Waste Water
Signitule Haul pate
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