HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 129 CHRISTIAN WAY 12/12/2019 Commonwealth of Massachusetts RECEIVED
City/Town of pEC 1 ? 201q
System Pumping Record T NURZ H ANgu\ R
Form 4 ,I.'tN Df
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 Locatio Right ant of house, Left/Right rear of house, Left/right side of house, Left
Right side of bui ng, Left/Right front of building, Left/Right rear of building, Under deck
Address � a� cn�-�.
Citylrown Zip Code
2. System Owner.
Name
Address(if different from location)
Citylrown State L Zip e
3 a� �
Telephone Number
B. Pumping Record
l
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Type of system: ❑ Cesspool(s) eptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? es ❑ No If yes, was it cleaned? es ❑ No
5. Condition oEystem:
6. Systenii Pumped By:
Neil.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Location where contents were disposed:
LSO O Lowell Waste Water
SignAtule 9t Haul Date
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