HomeMy WebLinkAboutseptic tank - Septic Pumping Slip - 141 STONECLEAVE ROAD 5/18/2020 RECEIVE®
:-C\ Commonwealth of Massachusetts MAY 18 2020
= City/Town of
System Pumping Record TOWN of i OEF rl TMENTANUUV R
Y p g HEALTH DEPAi3Tt��lRlT
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.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 y g a/Righ ear of housE,'Left/right side of house, Left
Right side of building, Left/Right front of building, Left/Right rear of building, Under deck
Address
City/Town state Zip Code
2. System Owner.
Name
Address(if different from location)
City/Town State- Zip Code
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 D No If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
6. System Pumped By:
Neil.Bates-on F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Locatpi!pwhere contents,were disposed:
S Lowell Waste Water
Sign a 9tHaul Date
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