HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 410 SUMMER STREET 4/1/2020 Commonwealth of Massachusetts RECENEr-
Ci /Town of R
tY AP
System Pumping Record rown,o�
Form 4 HEALTH pEP RTMENV ER
r
DEP has provided this form for use by local Boards of Health. Other forms maybe used,but the
information must be substantially the same as that provided here. Before using.this form,check with your
focal 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 eft ighaear of house Left/right side of house, Left
Right side of building, Left/Right front of building, Left/Right rear of building, Under deck
Address
Citylrown State Zip Code
2. System Owner. LCL6-\p-�Y\
Name
Address(if different from location)
CityfTown State l Zip Code
Telephone Number
B. Pumping Record
c.
1. Date of Pumping p 2. Quantity Pumped: Gallons
3. Type of system: ❑ Cesspool(s) eptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? a I-e-s ❑ No If yes, was it cleaned? es ❑ No
5. Condition of System:
6. System Pumped By:
Neil.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Loca' ere contents were disposed:
G L S Lowell Waste Water
SignAqe fHtulmuDate
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