HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 115 COLONIAL AVENUE 4/30/2020 : Commonwealth of Massachusetts RECE►vED
City/Town of APR 3 0 ,toy"d
System Pumping Record TOWN MENT
OFNURZHANUUVER
Form 4 HEALTH DEPART
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 Locatio . e ron of hou , Left/Right rear of house, Left/right side of house, Left
Right side of buldifig, Left/Right ron of building, Left/Right rear of building, Under deck
Address Lo �eq�,4 C:��_
CRY/Town state Zip Code
2. System Owner. � r\
Name"
Address(i different from location)
CitylTown State'w C�— Cod
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2 Quantity Pumped: Gallons
3. Type-of system: ❑ Cesspooks) eptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes o If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
6. System Pumped By:
Neil.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Ina
Company
7. Location where contents were disposed:
G L S Lowell Waste Water
sign a Haul Date
t5fomm4.doc•06/03 System Pumping Record•Page 1 of 1