HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 161 BRIDGES LANE 4/23/2020 Commonwealth of Massachusetts �,� 7� ��h , m
City/Town of ~
System Pumping Record NOV a 8 2019
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, 19 rear of of use)Left/right side of house, Left 1
Right side of building, Left/Right front of buii lrig, Left/FZ19 h t Tearffbuilding, Under deck
Address /� C PCt
rown State Zip Code
2. System Owner.
Name'
Address(if different from location)
CitylTown State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2 Quantity Pumped:
Gallons
3. Type-of system: ❑ Cesspool(s) M-8 pfic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes o If yes,was it cleaned? ❑ Yes ❑ No
5. Condition of System, : �-
6. System Pumped By:
Neil.Batesbn F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. L contents-were disposed:
Cs.L S: Lowell Waste Water
Signftfe cl HauleiU Date
t5fomu4.doa O6/03 System Pumping record•Page 1 of 1
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