HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 101 COLONIAL AVENUE 11/4/2019 Commonwealth of Massachusetts
City/Town of
System Pumping Record
Form 4
DEP has provided this form for uw.by local Boards of Health.Other forms may 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 —�e_1. System Location: eft/ ' fro ght nt of housLeft/Right rear of house, Left/right side of house, Left
Right side of buff i eft/Right front of building, Left/Right rear of building, Under deck
Address k� �
Cfty/Tom ( �/ State Zip Code
2. System Owner. (�
Name'
Address(if different from location)
CitylTown state-
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2 Quantity Pumped:
Gallons
3. Type-of system: ❑ Cesspool(s) 0-866p c Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes 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. L e contents-were disposed:
G L S Lowell Waste Water
-C C�
Sign a Haul pate
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