HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 443 BOSTON STREET 5/18/2020 RECEIVED
..� Commonwealth of Massachusetts
_ City/Town of W 18 2020
System Pumping Record Tom OF�jEWjjp�P RTMeNi �
Form 4
4 5�
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: Le Right front of houseeft/Right rear of house, Left/right side of house, Left
Right side of building, Le t frontofbuilding, Left/Right rear of building, Under deck
Address ( r
CWTown State Zip Code
2. System Owner. % r
Name
Address(if different from location)
City/Town Staf Zip Code
Telephone Number
B. Pumping Record
5-- 3
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Type of system: ❑ Cesspool(s) az&ptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes a-M-0— If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
r
6. System Pumped By:
Neil.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Locaa lZ\e contents were disposed:
G L Lowell Waste Water
C3 C�
Sign a Haul g Date
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