HomeMy WebLinkAboutseptic tank - Septic Pumping Slip - 4/1/2020 :&\. Commonwealth of Massachusetts
City/Town of
h. System Pumping Record
Form 4
DEP has provided this form for us&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 forrh 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: Le ht nt of house Left/Right rear of house, Left/right side of house, Left/
Right side of building, Left/Rig o uilding, Left/Right rear of building, Under deck
Address ��_
��
Cftylrown State Zip Code
2. System Owner.
Name'
Address(if different from location)
Telephone Number
B. Pumping Record
1. Date of Pumping gate �2_ ,Ql�uainfiPumped: Gauons
3. Type of system: ❑ Cesspool(s) tic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes LSO 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. LT"GLS.
ere ontente were disposed:
Lowell Waste Water
on a Haul Df
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