HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 75 GRANVILLE 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 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 houVu�&dihngc,
htnt�
ide f house, eft
Right side of building, Left/Right front of building, Left/Right rear
Address '7.� 6 CCLA.k�, e
CttyR� l State Zip Code
2. System Owner.
Name'
Address(if different from location)
CitylTawn State- � �Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped:
Gallons
3. Type-of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes 5 No If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System: P n4
S. System Pumped By:
Neil.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Location where contentar were disposed:
ALLS-0 Lowell Waste Water
14raA. 6�����
75ignAwfe qt HaulerU Date
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