HomeMy WebLinkAboutseptic tank - Septic Pumping Slip - 75 DUNCAN DRIVE 11/26/2019 Commonwealth of MassachusettsGE�v��
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City/Town of Nod 2o��N M N
System Pumping Record oFN �QP�
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 house, Left/right side of house, Left/
Right side of building, Left/Right front of building, Left/Right rear of building, Under deck
Address �� }
V �
City/Town State Zip Code
2. System Owner ,y
Name" (J�
Address(f different from location)
ciWown State
Telephone Number
B. Pumping Record
1. Date of Pumping Date ;r2___ Quan' umped: Gallons
3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes o 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. Loca' e contents were disposed:
G L S ` Lowell Waste Water
Sign a Haul Date
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