HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 66 CEDAR LANE 4/23/2020 :N 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 house, Left/Right rear of house, _righ id off hoouus'S, Left 1
Right side of building, Left/Right front of building, Left/Right rear of building, Under deck
Address _ I_"LI-1 c e AAl
City/Town state Zip Code
2. System Owner.
Name
Address(if different from location)
Cityrrown State- Zip Cade
—73 — t
Telephone Number
B. Pumping Record
1. Date of Pumping pate 2. Quantity Pumped:
Gallons
3. Type of system: ❑ Cesspool(s) eptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System: "
�J AA (,aj,(
6. System Pumped By:
Neil.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. LonLS.,,w
here contents-were disposed:
Lowell Waste Water r
Signibile cf Hamulwupate
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