HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 314 CLARK STREET 11/26/2019 ECER �
Commonwealth of Massachusetts v 26 20I
City/Town of �o
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 housedkb Righ L right side of house, Left 1
Right side of building, Left/Right front of building, Leftd eanobu:iel�d:j/4, Under deck
Address � 1�--t /���,� I �-C� �5�•--
City/Town [/ Stake Zip Code
2. System Owner.
Name f
Address(if different from location)
City/Town State 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 No If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of SyNjr �
6. System Pumped By:
Neil.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Locati contents were disposed:
�L S: Lowell Waste Water
Sign a Haul Date
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