HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 426 SUMMER STREET 3/2/2020 Commonwealth of Massachusetts RECEIVED
City/Town of MAR G 2 2020
System Pumping Record NORTH
OF
Form 4 TOWN
H,AJ..TH DEPARTMENT
ER
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: Left/Right front of house, Leftpit,ght rear of houses, Left/right side of house, Left/
Right side of building, Left/Right front of building,TefFl Right-rear of building, Under deck
Addressq,`�
City/Town State Zip Code
2, System Owner.
Name
Address(if different from location)
Cityrrown
State o d
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2- Quantity Pumped:
Gallons
3. Type of system: ❑ Cesspool(s) [Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
6. System Pumped By:
Neil.Bates-on F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. laA.
jSigne
ere contents were disposed:
Lowell Waste Water
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Hauleru Date
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