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HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 131 GRANVILLE LANE 10/21/2019 Commonwealth of Massachusetts = City/Town of System Pumping Record OCT 21 ?01q 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, Left/Right rear of hous. Lei/right side of house-Left 1 Right side of building, Left/Right front of building, Left/Right rear of building, Under deck Address � •.� �. � (�c;�C��_ ���2_ �'�, City/Town State Zip Code 2. System Owner. Name Address(if different from location) Citylrown aa* o 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): s� 4. Effluent Tee Filter present? ❑ Yes ❑'No 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: Lowell Waste Water jSigneWHaul — Date t5form4.doa 06/03 System Pumping Record•Page S of 1