HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 90 SPRING HILL ROAD 10/21/2019 Commonwealth of Massachusetts -._ __%
TCity/Town of
System Pumping Record OCT 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 Location: Left/Right front of house, LeKCRiaht 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
Mylrown State Zip Code
2. System Owner.
Name '--
Address(if different from location)
City/Town S
Uf
Telephone Number
B. Pumping Record
1. Date of Pumping pate 2. Quantity Pumped: Gallons
3. Type of system: ❑ Cesspool(s) Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes ❑ No If yes, was it cleaned? ❑-Yes—❑ No
5. Condition ofSlystem:
���
6. System Pumped By:
Neil.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Location where contents-were disposed:
G-LS-P Lowell Waste Water
�ign a Haul Date
t5form4.doc•06/03 System Pumping Record•Page 1 of 1