HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 235 FARNUM STREET 11/12/2019 RECENE�
Commonwealth of Massachusetts NOV 2 2019
City/Town of of Nop'lH pNooVER
EXT
System Pumping Record 10 .jHo�' �"'
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 Locatio�Rig fr t of house Left/Right rear of house, Left/right side of house, Left
Right side of boil ing, Left/Rig ron of building, Left/Right rear of building, Under deck
Address
City/Town State Zip Code
2. System Owner.
Name
Address(if different from location)
Cityrrown Z Code
;q� d� p
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):
4. Effluent Tee Filter present? ❑ Yes [14I / 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-
�Sp Lowell Waste Water
Sign a Haul Date
t5form4.doa 06/03 System Pumping Record•Page 1 of 1