HomeMy WebLinkAboutPump Tank - Septic Pumping Slip - 247B FARNUM STREET 12/12/2019 : RECE1vV
_ Commonwealth of Massachusetts Zp�g
ONIMEMEMM
11 City/Town of
N�
System Pumping Record 10 ,e �M�'t
Form 4 H
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, eft% 'gh ftWq�'��f'
1
Right side of building, Left/Right front of building, Left/Right rear of buP ing, Und
Address � �-7
Citylrown •� State
Zip Code
2. System Owner.
Name
Address Of different from location)
CwTown Zip Code
\
Telephone Number
B. Pumping Record
1. Date of Pumping Sate 2. Quantity Pumped:
Gallons
3. Type-of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank
�erdescribe): -
4. Effluent Tee Filter present? ❑ Yes ❑ No 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. �T(G_LS
ere contents were disposed:
Lowell Waste Water
on a Haul Date
t5form4.doa 06/03 System Pumping Record•Page 1 of 1