HomeMy WebLinkAboutSeptic Tank - Pump Tank - Septic Pumping Slip - 7 HAY MEADOW ROAD 1/28/2020 Commonwealth of Massachusetts C�ECE�vED
City/Town of
System Pumping Record BAN 2$207�'
Form 4 NOR1N PNN R
SC`N�OF RSME
��NDEPF,
DEP has provided this form for use-by local Boards of Health. Other forms may b�us ed,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 hous , rg ear ff hous eft/right side of house, Left
Right side of building, Left/Right front of g, Left/Wear
of building, Under deck
Address
CilyRown State Zip Code
2 System Owner.
Name'
Address(ir different from location)
City/Town state CG 4`�P'_,5,� Zip code
Telephone Number
13. Pumping record
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Type-of system: ❑ Cesspool(s) eptic Tanl � Tight Tank
D-06e_r(describe):
4. Effluent Tee Filter present? ❑ Yes ❑ No If yes, was it cleaned? ❑ Yes ❑ No
5. Condition stem.
'r VN_
6. System Pumped By.
Neil.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Location where contents-were disposed:
G L S Lowell Waste Water
Sign We cfHaulerUDate
t5form4.doc-06103 System Pumping Record•Page 1 of 1