HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 150 BRADFORD STREET 10/21/2019 Commonwealth of Massachusetts
• City/Town of
System Pumping Record OG 21 2019
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 Locatiom kek/Right fLonf of hou es ; ..eft/Right rear of house, Left/right side of house, Left
Right side of building, Left/Right front of building, Left/Right rear of building, Under deck
Address n '
City/Town State Zip Code
2. System Owner.
bit SG`
Name'
Address(if different from location)
City/Town State n Zip Code
Telephone Number
B. Pumping record
1. Date of Pumping . Quantity Pumped: `�--
Date Gallons
3. Type of system: ❑ Cesspool(s) (3 Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes �tNo 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. Location where contents were disposed:
G L S Lowell Waste Water
Cb
Sign a Haul Date
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