HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 296 BERRY STREET 4/30/2020 RECEIVED
Commonwealth of Massachusetts
City/Town of APR 0 20
MER
System Pumping Record TOHULWN TH P PARTM NT
HEP,!Tu^Ir�'�;RTMENT
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 fors 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, Left/right side of house, Left
Right side of building, Left/Right front of building, Left/Right rear of building, Under deck
Address
City/Town State Zip Code
2. System Owner.
Name
Address(if different from location)
Cityfrown State-
(,'
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Type-of system: ❑ Cesspool(s) U18 ptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes Dl Wo 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. LocatiGnwhere contentawere disposed:
G LS-0 i Lowell Waste Water
SigWeH4,aul Date
t51orm4.doa-06/03 System Pumping Record•Page 1 of 1