HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 21 EASY STREET 4/1/2020 Commonwealth of Massachusetts RECEIVED
_ City/Town of APB 12020
System Pumping Record MMOMMUNMOMM
Form 4 HEALTH DE
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/R�h nt of house,left/Right rear of house, Left/right side of house, Left I
Right side of building, Left/Right ro�`nt of buildirig, Left/Right rear of building, Under deck
Address
CfWTown State Zip Code
2. System Owner:
Name'
Address(if different from location)
City/Town Stafe/`l ! Zip Code
Telephone Number
C�LLr
B. Pumping Record
-Au
1. Date of Pumping Date 2- Quantity Pumped:
Gallons
3. Type of system: ❑ Cesspool(s) U-3€ptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes a No If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System: (; i "
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
7 ��
Sign a Raul Date
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