HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 76 EVERGREEN DRIVE 5/18/2020 RECEIVED
Commonwealth of Massachusetts MAY 18 2020
City/Town of
System Pumping Record TOM BEA�T80;90 " R t
Form 4
DEf has provided this form for use-by local Boards of Health. Other forms may 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 front of house, Left 'g of house, Left/right side of house, Left
Right side of building, Left/Right front of building, Left/Right rear of building, Under deck
Addres176s
C'21, Pam''' -
cityRown State Zip Code
2. System Owner. I
Name
Address(if different from locafion)
CityfTown State �Zip Code
6 r
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 Ulpd If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
Lj
6. System Pumped By:
Neil.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Ina
Company
7. Loca' ere contents-were disposed:
G L S Lowell Waste Water
Signk4e flftuleluDate
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