HomeMy WebLinkAboutSewer Lift Station - Septic Pumping Slip - 50 WILD ROSE DRIVE 10/21/2019 : Commonwealth of Massachusetts
City/Town of
System Pumping Record OCII 2 1 20!0
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 q'g front of hou , Left/Right rear of house, Left/right side of house, Left
Right side of building, Le ig front of building, Left/Right rear of building, Under deck
Address A '
Citylrown w V estate Zip Code
2. system Owner.
Name
Address(if different from location)
City/Town state 11� i code
Gam.
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Type-of system: ❑ Cesspool(s) ❑ Septic Tank Tight Tank
Other(describe): s
4. Effluent Tee Filter present? ❑ Yes ❑ No If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of
6. System Pumped By:
Neil.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Lo ere contents-were disposed:
G L S Lowell Waste Water
Sign aqtHaulwu Date
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