HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 10/21/2019 C_ Commonwealth of Massachusetts
City/Town of
System Pumping Record
Form 4
DEP has provided this form for use by local Boards of Health. Other forms may beused, 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 house, Left/right side of house, Left
Right side of building, Left/Right front of building, Left/Right rear of building, Under deck
Address
CitylTown State '�I Zip Code
2: System Owner.
Name
Address(if different from location)
CitylTown State Cede
�`� �p5
Telephone Number
B. Pumping Record
CC)
1. Date of Pumping Date 2- Qua 'ty Pumped: Gallons
3. Type of system: ❑ Cesspool(s) Septic 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. Locaoon-where contents were disposed:
G L S Lowell Waste Water
Sign a qf Haut Date
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