HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 69 OAKES DRIVE 4/1/2020 : Commonwealth of Massachusetts RFCEiVE
IWMEM City/Town of AP D
System Pumping Record TowNO R
Form 4 till,
-
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/Right front of house a �- useft/right side of house, LeftRight side of building, Left/Right front of bul ng, Lelding, Under deck
Address 04? _
city/Town State Zip Code
2. System Owner.
Name
Address(if different from location)
CitylTown S
Telephone Number
B. Pumping record
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Type-of system: ❑ Cesspool(s) eptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes a No If yes, was it cleaned? ❑ Yes ❑ No
5. Condition Syste'C./�
6. System umped By:
Neil.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Lo =SP
e contents-were disposed:
Lowell Waste Water
Sign aCfHauwuDate
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