HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 209 BRIDGES LANE 11/4/2019 : 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 be Lsed, 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 }�+i�a� hes�p, Left/right side of house, Left,/
Right side of building, Left/Right front of building, Left/Right rear of building, Under deck
Address
CKyRo" State Zip Code
2. System Owner.
Name' V�
Address(iP different from location)
Cdyfrown State '.�1� Zp code
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped:
Gallons
3. Type-of system: ❑ Cesspool(s) eptic Tank 'Fight Tank
❑ Other(describe):
4. Effluent Tee Filter present? 9—f' ❑ No If yes,was it cleaned? D-Y9i0 No
5. Condition of rst0 yr "\_�
6. System Pumped By:
Neil.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7=�S.
ontents-were disposed:
7 Lowell waste water n
ign a qt hftuleV pate
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