HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 208 SUMMER STREET 12/12/2019 : Commonwealth of Massachusetts RECE�vED
City/Town of I 2 2p19
System Pumping Record pEC
Form 4 RZH ANpOVER
0 N't
�0�0`N pEPPR�ME
DEP has provided this form for use=by local Boards of Health. Other rms 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 ��g U v"A
Mylrown State Zip Code
2. System Owner.
Name'
Address(if different from location)
CWTovm state �
Telephone Number
B. Pumping record
1. Date of Pumping Dam 2. Quantity Pumped:
Gallons
3. Type-of system: ❑ Cesspool(s) eptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes 9_ No If yes,was it cleaned? ❑ Yes ❑ No
5. Condition of stem:
a's-C�
6. System Pumped By:
Neil.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Locati ere contents-were disposed:
G L S Lowell Waste Water
Sign a lHaLdW Date
t5fom4.doa 06/03 System Pumping Record•Page 1 of 1