HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 1620 TURNPIKE STREET 12/23/2019 :�L\ Commonwealth of Massachusetts RECENED
City/Town of DEC 2 3 7019
System Pumping Record UFNDRIHANDUVER
Form 4 TO HAt TH 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 h use, Left/Right rear of house, Left/right side of house, Left
Right side of building,AAD Rjg6tro of bui m Left/Right rear of building, Under deck
Address
—TSt)
City/Tom State Zip Code
2. System Owner. JJ QQ
Leod 1 � 0Name �u O[A
Address(if different from location)
C' own p
stag e
`1 R tt- 1 'fib 0
Telephone Number
B. Pumping Record
1. Date of Pumping date 1 t -1 2. Quantity Pumped:
Gakons
3. Type-of system: ❑ Cesspool(s) Ea/septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes to If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of Syst
6. System Pu ed By:
Neil.Bateson
Name Vehicle License Number F
Bateson Enterprises Ina
Company
7. Location where contents-were disposed:
Lowell Waste Water
Signiture 9t Him pate
t5fomn4.doc-06/03 System Pumping Record•Page 1 of 1
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