HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 285 REA STREET 4/23/2020 K1--k;F=1VED-
Commonwealth of Massachusetts NOV 07 2019
City/Town of BOARD OF
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 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 �Righ r�hous6, Left Right rear of house, Left/right side of house, Left
Right side of buil ' g, Left/Rig o JWMuildifig, Left/Right rear of building, Under deck
Address
City/Town State Zip Corse
2. System Owner. RECEIVED
Name
Address(if different from location) O VER
10 ��TH DEPARTMENT
Citynown Stat . ZIp22259
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? es ❑ No If yes, was it cleaned? es ❑ No
5. Condition of System*
6. System Pumped By:
Neil.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Loca a contents were disposed:
G L S Lowell Waste Water
1_4 ----- /i=:�) -3
Sign a Haul Date
t5form4.dor,-06/03
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