HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 45 TURTLE LANE 5/18/2020 RECEIVED
: Commonwealth of Massachusetts MAY 18 2020
City/Town of
System Pumping Record Ht M
Form 4
DEP has provided this form for use-by local Boards of Health. Other forms may be used,but the
information,must be substantiW 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/RighUgDn24yse; gj Right rear of house, Left/right side of house, Left 1
Right side of building, Left/Right front of building, Left/Right rear of building, Under deck
Address
Cityfrown State Zip Code
2. System Owner.
Name.
Address(if different from Iodation)
Tip
Cwrown state Code�� �
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped:
Gallons
3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes No If yes,was it cleaned? ❑ Yes ❑ No
5. Condition of System:
6. System Pumped By:
Neil.Batesbn F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Location where contents-were disposed:
�L S Lowell Waste Water
Sign aItHaulwuDate
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