HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 66 JAY ROAD 12/12/2019 ._ Commonwealth of Massachusetts RE�E�VED
City/Town of
System Pumping Record DEC 2 201E
ZH ANppvER
Form 4 '(0 Nam`H p PPRTMENT
DEP has provided this form for use:by local Boards of Health. Other forms may beused,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: LeftleikPi7§ht
nt of hou Left/Right rear of house, Left/right side of house, Left
Right side of building, front of building, Left/Right rear of building, Under deck
Address
City/Town State Zip Code
2. System Owner.
Name
Address(if different from location)
CWrown State ((�� _ Zi Cod j
dQ s ``�f Fs-o P
Telephone Number
B. Pumping Record
1. Date of Pumping 2 Quanti Pumped:
Date ty p Gallons
3. Type-of system: ❑ cesspool(s) eptic 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.Batesbn F5821
Name Vehicle Ucense Number
Bateson Enterprises Inc
Company
7. Locatimwbere contentewere disposed:
L S Lowell Waste Water
7
Sign We qt HauterU Date
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