HomeMy WebLinkAboutseptic tank - Septic Pumping Slip - 162 ABBOTT STREET 4/1/2020 : Commonwealth of Massachusetts 44RC /�
City/Town of q�°R �®
System Pumping Record 'OHwN cOFNO'. ZQ20
Form 4 yoEp�RgNo���R
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, Left 4tffQht rear of house, Left/right side of house, Left 1
Right side of building, Left/Right front of building, Left/Right rear of building, Under deck
Address
City/Town State Zip Code
2. System Owner.
Name'
Address(if different from location)
CiVrown State- Zi Code
Telephone Number
B. Pumping record o
1. Date of Pumping Date2. 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.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc-
Company
7. Location h e contents were disposed:
�L S Lowell Waste Water
SignAtule Haut Date
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