HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 26 EASY STREET 4/28/2020 : Commonwealth of Massachusetts
i v City/Town of 2 202Q
System Pumping Record cc
Form 4 a.
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�fr6nofsbuild?ihg,
ft/Right rear of house, Left/right side of house, Left
Right side of building, Le R Left/Right rear of building, Under deck
Address
Citylrown State Zip Code
2. System Owner.
Name
Address(if different from location)
City/Town Stat Z' de
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 f NO 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. Locatio a contents were disposed:
^L S Lowell Waste Water
i-
Sign a f Haul Date
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