HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 35 HOLLOW TREE LANE 4/30/2020 _ Commonwealth of Massachusetts RECEIVED
_ City/Town of APR 3 0 200
System Pumping Record TOWN ViFALIH DEPARTMENT ANUUVER
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 Ahis 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/fZight�ront of house,_Left/Right rear of house, Left/right side of house, Left/
Right side of building, Left tRRight ron o building, Left/Right rear of building, Under deck
Address > � —��
C"rtylrown State Zip Code
2. System Owner kq�eA-�
Name
Address(if different from location)
Citylrawn State Zi Code
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Type of system: ❑ Cesspool($) [Ipeptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes Er,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. LocationAuhere contents-were disposed:
G LS-P Lowell Waste Water
Sign we fHaul Date
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