HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 178 BRIDGES LANE 12/12/2019 Commonwealth of Massachusetts
City/Town of RECEIVED
System Pumping Record pEC 1 Zp1g
Form 4 r�wN OF NDR1H ANppVER
HEAt.TN DEPARTMENT
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, Lett/
Right side of building, Left/Right front of building, Left/Right rear of building, Under deck
Address L),,A_
CiWrown State Zip Cone
2. System Owner.
Name
Address(if different from location)
City/Town state Zi
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped: GaOons
3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes Io 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. Location where contents-were disposed:
r�
G L S Lowell Waste Water
Signitute crHaulerUDate
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