HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 4/1/2020 Commonwealth of Massachusetts Rr-�ENED
= City/Town of
System Pumping Record FN�RIHANDaVER
Form 4 �� �jK� pEPARTMENS
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 farm 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 hous �E%n I e o h�seXeft/
Right side of building, Left/Right front of building, Left/Right rear o9,UL;V—c`mg, Un er ec -
Address
Citylrown state Zip Code
2. System Owner.
Name
Address(if different from location)
CiVrown State- Zio Co
Telephone Number
B. Pumping record
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Type of system: ❑ Cesspool(s) a-864-tic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes o 7-� 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. Locatio J Wcontentsrwere disposed:
G L S Lowell Waste Water
Sign a Kaul Date
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