HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 145 CRICKET LANE 5/18/2020 RECEMD
Commonwealth of Massachusetts MAY 18 2020
City/Town of
VER
System Pumping Record TOWNL HL)EPA NORTH AF+1ENT
Y p g HEALTH DEPARTMENT
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/Righ"r nt of house eft/Right rear of house, Left/right side of house, Left
Right side of building, Left/Right ron o uildirig, Left/Right rear of building, Under deck
Address
CWTown state Zip Code
2. System Owner. �1
Name
Address(if different from location)
Cityffown state �rd�
Telephone Number
B. Pumping Record t _
1. Date of Pumping Date 2. Quantity Pumped: Gallon
s
3. Type of system: ❑ Cesspool(s) ptic 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.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Location where contents,were disposed:
G L S Lowell Waste Water
Signiture Haul Date
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