HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 1 SCOTT CIRCLE 4/23/2020 ° F�V '
Commonwealth of Massachusetts
City/Town of NOV o'7 2019
M° System Pumping Record BOARD O H ALTH
Form 4
DEP has provided this form for use=by local Boards of Health. Other forms may beused, 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 d�Ceff LRi t'rear of house�ft/right side of house, Left
Right side of building, Left/Right front of building, Le Mght reaf o�building, Under deck
Address � C' �e _-�., _ . • ti
CitylTown State Zip Code
2. System Owner. v\ rN()FNORpPR M
< W E
Name
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped:
Gallons
3. Type of system: ❑ Cesspool(s) eptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes D-Mo If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
6. System Pumped By:
Neil.Bateson F5821
Name Vehicle License Number
B_ateson Enterprises Inc
Company
7. Locati a contents were disposed:
G L S. ' Lowell Waste Water
Sign a Haul Data
t5form4.doc-06/03 System Pumping Record•Page 1 of 1
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