HomeMy WebLinkAboutseptic tank - Septic Pumping Slip - 80 PHEASANT BROOK ROAD 4/1/2020 Commonwealth of Massachusetts
City/Town of
System Pumping Record
Form 4
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 douse, Le Ri of i9uW, Left/right side of house, Left
Right side of building, Left/Right front of building, Left/Right rear of building, Under deck
Address Q
City/Town state Zip Code
2 System Owner.
Name
Address(if different from Mcation)
Cityflrown stater
Telephone Number
B. Pumping Record
1. Date of Pumping �.
p 9 Date Quantity Pumped:
Gallons
3. Type-of system: ❑ Cesspool(s) p c Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes 2 1vo__�_If yes, was it cleaned? ❑ Yes ❑ No
5. Conditipn Sysce_mu�
6. System Pumped
Neil.Batesbn F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Locatio ontentsrwere disposed:
�L S Lowell Waste Water
Sign a Haul Date
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