HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 350 BERRY STREET 11/19/2019 : Commonwealth of Massachusetts
0 if-
City/Town of
System Pumping Record Nov �1HA,SwvER
Form 4 1000SN pEPARTMENT
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 Locatior�. Righ fron OfN�of
Left/Right rear of house, Left/right side of house, Left 1
Right side of bulff�eft/Rlg railding, Left/Right rear of building, Under deck
Address
r v
cityRown state Zip Code
2. System Owner.
Name'
Address(f different from location)
CWTown
Telephone Number
B. Pumping Record
1. Date ofPum in
P 9 Date ;�Pll uantl mped: Gallons
3. Type of system: ❑ Cesspool(s) tic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System,
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6. System Pumped By:
Nell.Bateson F5821
Name Vehicle L►cense Number
Bateson Enterprises Ina
Company
7. Lo a contents-were disposed:
G,LS.JD Lowell Waste Water
W�ign Date
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